regional trauma centers, designation of base hospitals to provide medical direction to EMS personnel, establishment of regional medical policies and procedures, and licensure of EMS services.

Accountability is driven by a quality improvement program in which a medical audit committee meets monthly to review systemwide patient deaths and complications. The committee includes trauma directors; trauma nurse managers; the county medical examiner; the chief of EMS; and representatives of key specialty organizations, including orthopedic surgeons and neurosurgeons, as well as a representative for nondesignated facilities. A separate prehospital audit committee that includes ED physicians and prehospital providers also meets monthly and discusses any relevant prehospital issues.

An initiative currently under way in Palm Beach County, Florida, is more limited in scope than the systems highlighted above and is in the initial stages of development. The goal of the initiative is to find regional solutions to the limited availability of physician specialists who provide on-call emergency care services. In spring 2004, physician leaders, hospital executives, and public health officials formed the Emergency Department Management Group to address this problem. One approach being explored is to attack the rising cost of malpractice insurance for emergency care providers, which discourages specialists from serving on on-call panels. The organization is developing a group captive insurance company to offer liability coverage for physicians providing care in county EDs.

The Emergency Department Management Group is developing a web-based, electronic ED call schedule so the EMS system can track which specialists are available at all hospitals throughout the county. This will enable the system to direct transport to the most appropriate facility based on a patient’s type of injury or illness.

The Emergency Department Management Group is exploring the regionalization of certain high-demand specialties, such as hand surgery and neurosurgery, so that the costs of maintaining full on-call coverage can be