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Future of Emergency Care: Dissemination Workshop Summaries 4 Workshop in Chicago, Illinois The second dissemination workshop focused on the issues of workforce and hospital efficiency. The workshop began with remarks from Eric Whitaker, director of the Illinois Department of Public Health. He discussed the complexities of the emergency medical services (EMS) system in Illinois, noting that the state has 11 EMS systems and as many as 60 EMS medical directors. Of great concern is the lack of standardization of EMS practice from one region to the next. Problems in the EMS system came to light in Chicago during a summer heat crisis in 1995, when there were 465 heat-related deaths in the city. During that summer, 23 of 42 hospitals went on diversion, emergency department (ED) wait times exceeded 12 hours, and it took some ambulances more than 30 minutes to reach patients. The immense demand on system resources created difficulty in responding to all patients, not just those with heat-related emergencies. Dr. Whitaker noted that because EMS tends to be a local issue, local politics is a challenge to reform. Because of the political challenges, federal guidance is needed to lead states in the right direction. Dr. Whitaker encouraged federal agencies to coordinate their efforts so that activities at the state and local levels can also be better coordinated. REACTIONS TO THE IOM REPORTS Regional Perspectives After three Institute of Medicine (IOM) committee members—Brent Eastman, Nels Sanddal, and Joseph Wright—provided a summary of the
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Future of Emergency Care: Dissemination Workshop Summaries findings and recommendations from the IOM reports, a panel of state and local representatives participated in a conversation about the reports based on a series of questions set in advance. The discussion was moderated by Dr. Eastman, chief medical officer of ScrippsHealth. Respondents included Leslee Stein-Spencer, former chief of EMS for Illinois and current policy advisor for the National Association of State EMS Officials; Bill Jermyn, EMS medical director for the state of Missouri; Stephen Hargarten, chair of emergency medicine at the Medical College of Wisconsin and director of the Injury Research Center; Thomas Esposito, trauma surgeon from Loyola University Medical Center; and Peter Butler, executive vice president and chief operating officer at Rush University Medical Center. What Are the Key Messages of the IOM Reports? Ms. Stein-Spencer identified several key messages of the report. First, she noted that the reports identified EMS as an important component of the health care system; one that should be elevated in importance. Second, ED crowding, boarding, and diversion are major system-wide problems. Third, there is a great need for improved coordination among federal, state, local, and regional levels across the various system components, including EMS, hospitals, public health, and trauma. Fourth, due to a lack of research on emergency care, we lack the ability to determine whether many interventions are making a difference for patients. Fifth, there is a need to identify facilities that are prepared to properly handle pediatric patients. Finally, disaster preparedness involves not only police and fire but also EMS and hospitals. More training, funding, and equipment are needed to improve the medical response to disasters. Dr. Jermyn added two key messages, the first being the IOM committee’s recommendation to develop a coordinated, regionalized, and accountable emergency care system. Second, there is a need to “break down silos” between different components of the emergency care system. Dr. Esposito and Dr. Hargarten agreed with the key messages mentioned by the previous speakers. Dr. Hargarten added that the key messages from the reports are nested in their respective titles: Emergency Medical Services at the Crossroads; Hospital-Based Emergency Care: At the Breaking Point; and Emergency Care for Children: Growing Pains. Mr. Butler identified two other key messages. First, the problems in the emergency care system (e.g., uncertain quality, fragmentation among providers, millions without health insurance, and the need for information technology) are a microcosm of the broader problems in the health care system. Second, providers can address some of the problems, but tackling them will require leadership. The hospital community must take responsibility for addressing some of the system issues that are being discussed.
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Future of Emergency Care: Dissemination Workshop Summaries Are There Any Important Points that the IOM Reports Missed? Mr. Butler noted that the reports do not discuss how wildly successful EDs have been. The reports could have highlighted examples of best practices or case studies to describe what hospitals are doing well, rather than focus on shortcomings. He also noted that hospitals strive for high rankings in service lines, such as cardiac or cancer care; however, hospital quality is largely dependent on how well the functional areas, such as EDs, operating rooms, and intensive care units, perform. The reports should have emphasized the need for senior management to spend more time addressing quality issues in the functional areas of hospitals. Dr. Esposito emphasized the need to consider the continuum of the health care encounter. A patient today may need rehabilitation services or end-of-life care several weeks or months in the future. Also, although the reports discuss the challenge of meeting the demand for emergency care, there is little discussion of the appropriateness of the care demanded. Does every child who falls off of a bicycle without a helmet need to go to the ED? Greater attention should be given to the cultural and legal perceptions of what services are needed under different circumstances. Dr. Hargarten said that the IOM committee appropriately used the trauma model for their vision of a coordinated, regionalized, and accountable system; however, the reports could have described the emerging acute care systems for cardiac care, stroke care, toxicology care, and sepsis care, which are similar systems. He added that we should learn from leaders in pediatric emergency medicine, who have appropriately positioned the concerns of children with regard to emergency care, and develop a similar focus for geriatric care. In addition, Dr. Hargarten said that emergency care stakeholders need to develop a common, unified language when speaking about emergency care, trauma, and injury prevention and control to deliver a common message to policy makers. The reports fell short of developing a common language or a single message. Finally, Dr. Hargarten spoke about movement in the National Institutes of Health (NIH) toward translational research and the development of clinical translational science awards, which will be housed in approximately 60 centers across the United States. He expressed concern that the reports did not explicitly state that some of those centers should focus on translational emergency care research. Dr. Jermyn noted that one of the shortcomings of the reports is that they did not simplify the very complicated emergency care system into a straightforward model that legislators and the public can easily understand. Ms. Stein-Spencer added that the IOM committee should have devoted more attention in the reports to the National Emergency Medical Services Information System (NEMSIS). NEMSIS is collecting standardized data from states and will serve as a repository for information that can help
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Future of Emergency Care: Dissemination Workshop Summaries advance EMS research and EMS performance measures. She also noted that the report’s call for a single lead agency for emergency care at the federal level lacked an appropriate level of discussion and analysis about the problems that currently exist from having multiple agencies involved in emergency care at the federal level. What Are the Top Priority Areas for Action, and What Can Be Done to Address Those Areas? Ms. Stein-Spencer said that the top priority is figuring out how to generate and sustain funding for EMS systems. One way to address this is to make states accountable for the money that they receive from the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and other federal agencies. There should be better oversight of how the funding is spent. Another top area for action is to address the workforce shortages in order to improve surge capacity. Disaster preparedness plans often call for the creation of alternative health care facilities, but they fail to consider the fact that the workforce is often too limited to staff even traditional health care facilities. Dr. Jermyn also discussed the issue of funding, noting that emergency care is an essential public service, but it is not funded at a level comparable to police or fire services. Unlike the other two services, emergency care is funded when EMS transport is provided or when treatment is provided in the ED. An unintended consequence of this reimbursement system is that there is little surge capacity. Hospitals are encouraged to be efficient and, as a result, have limited bed vacancies. A change in the reimbursement structure is needed in order to address system preparedness. In the short term, Dr. Hargarten said that there must be a common language and vision for the emergency care system that can be easily conveyed to Congress in order for stakeholders to better advocate for change. In the long term, universal health insurance is needed. The growth of emergency care in previous decades is largely the result of poor access to primary and acute care. In the absence of universal health insurance, all other initiatives are simply Band-Aids on a larger problem. Dr. Esposito described results from a Harris poll cosponsored by the Coalition for American Trauma Care, the American Association for the Surgery of Trauma, and other surgical organizations. Once the respondents realized that not all hospitals are capable of providing high-level trauma care, and that trauma centers cannot be found in all communities, they said that they would be willing to pay for improved access to those services. Dr. Esposito also agreed that the workforce shortages must be addressed, perhaps by offering loan forgiveness programs or other incentives to emergency care providers. Similar to the point made by Ms. Stein-
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Future of Emergency Care: Dissemination Workshop Summaries Spencer, Dr. Esposito emphasized the need for states and hospitals to be held accountable for the public funding that they receive. Also, states and hospitals should be given greater direction on how to use the funding, perhaps through a technical advisory center. Mr. Butler downplayed the importance of funding, noting that even with increased resources, there are things providers must do to address the problems identified in the report. He noted that, like many hospitals across the country, Rush University Medical Center is building a new ED that is twice the size of the current one and will be equipped with negative-pressure rooms and other resources needed in the event of a disaster. As hospitals invest in these new facilities, it is imperative that they think through the needs of the community. Once the structure is built, it is very difficult to make further changes. Mr. Butler ended the session by noting that no matter how long people wait in the ED, or how difficult registration is, or whether quality is compromised, the public continues to return to the ED, and they are doing so in increasing numbers. ED care is the most successful service line for hospitals in terms of demand for care. “Imagine what it would be like if we could get it right!” Open Discussion Members of the audience were invited to make a brief comment or pose a question to the IOM committee members in attendance. Many of the questions and comments concerned how stakeholders can get the attention of policy makers and advance some of the IOM committee’s recommendations. Frederick Blum, president of the American College of Emergency Physicians (ACEP), described ACEP’s media and advocacy efforts over the previous year and asked what the next steps should be. Steven Krug from Children’s Memorial Hospital noted that the majority of the IOM committee’s recommendations are targeted to the federal level and will require congressional action. He asked what could be done collectively to encourage action on the top-down recommendations. Sonny Saggar, president of the U.S. Alliance of Emergency Medicine, raised a similar question about how to convey the messages from the IOM reports to the public and Congress in language they will understand. In response to these questions, Mr. Sanddal noted that, with the upcoming election, it is unclear whether there will be a new set of congressional leaders in one or both houses. If there is a transition, it may provide some opportunities for advocacy that emergency care stakeholders should leverage. Brent Asplin of Regions Hospital also noted that emergency providers have stories to share with policy makers that are very compelling. As for advocacy, he recommended that stakeholders try to advance a nonpartisan
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Future of Emergency Care: Dissemination Workshop Summaries recommendation—specifically, the demonstration program. While a demonstration project is not necessarily going to change the face of emergency care immediately, it is something that could pass and lead to better information on emergency care systems in the future. Dr. Wright added that, while providers do not want to scare the public, people need to be educated on the issues. He works two miles from the Pentagon and in presentations uses a picture of the Pentagon burning during September 11 to discuss what would have happened if the Pentagon was full of children. He encouraged attendees to provoke public thought and action. He also discussed the power of the print media. A couple of weeks ago, on a Sunday, there was an op-ed piece published in the Washington Post on the emergency care system. He said that many people outside his profession approached him about the article. Todd Allen, an emergency physician from LDS Hospital in Salt Lake City, observed that many different emergency care organizations have reacted to the IOM reports, each with its own agenda. He added that if a coordinated, integrated, and unfragmented emergency care system is the goal, then coordinated, integrated, and unfragmented leadership is needed to drive that process. Dan Hermes, a fire chief representing the Illinois Fire Chiefs and the International Fire Chiefs EMS section, described the experience of the fire chiefs in their efforts to influence policy makers. In the past, there were many stakeholders in the fire community who “worked in silos” and advocated to policy makers for their own issues with limited success. Legislators told the advocates to return with a clearer message, so the groups formed a caucus, which produced two benefits. First, all the different stakeholders now know what the others are doing and make sure that they are not developing competing messages. Second, it is easier to identify the areas in which all groups agree and to develop a clear message to policy makers. Emergency care stakeholders should consider doing something similar. James Augustine, an emergency physician and medical director and assistant fire chief for Atlanta Fire, suggested that stakeholders talk about success stories in EMS and EDs as a way to gain support for increased funding for emergency care. Linda McKibben from the Lewin Group noted that geriatricians, like pediatricians, serve a unique patient population that brings special challenges to the delivery of emergency services. She suggested the creation of coalitions among stakeholders and providers, including geriatricians, to work together for change. A number of attendees also made specific comments about other issues. Dr. Camilla Sasson from the Emergency Medicine Residents’ Association explained that the association developed a task force to review the IOM reports. That task force made several recommendations, one of which is to
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Future of Emergency Care: Dissemination Workshop Summaries undertake a team approach with physicians, nurses, and emergency medical technicians (EMTs) to develop federal legislation to present to policy makers. Second, there should be more funding for resident training to improve disaster preparedness, not just for emergency medicine residents, but for residents in all specialties. In the event of a disaster, physicians from various specialties will be needed to respond, and all should have training. And third, the federal program that offers loan forgiveness for primary care physicians practicing in rural areas should be extended to emergency medicine physicians as a way to bring board-certified, residency-trained physicians to rural areas. Dr. Eastman invited Dr. Sasson to comment on the younger generation of emergency physicians’ attitudes about work-life balance. Dr. Sasson explained that young physicians view their lives outside medicine as very important and may not work as many hours or for as many years as previous generations of emergency physicians. The liability problem in particular serves as a disincentive to continue practice, especially when some emergency medicine physicians can work in the information technology field, for example, for twice the salary with fewer work hours. Paula Willoughby DeJesus, EMS medical director for the Chicago Fire Department and from the American College of Osteopathic Emergency Physicians, cautioned that plans for regionalization of emergency care services must be practical. It would be difficult for ambulances to go to one hospital for geriatric care, another for pediatric care, another for cardiac care, and so on. She also expressed the need to be explicit about which hospitals should receive support for uncompensated care if Congress heeds the IOM committee’s recommendation to make new funding available to hospitals that provide a significant amount of uncompensated emergency care. A hospital may provide limited amounts of care to the uninsured and then send patients to another hospital to finish the treatment. It is important to make sure that funds are directed to the hospitals that are true safety-net providers. Hunt Batjer, chairman of neurosurgery at Northwestern University, noted that last year less than one-tenth of adult stroke patients were treated with either intravenous or intra-arterial thrombolysis. The reason the fraction is so small is because many of the victims were taken to the closest ED, rather than the ED that was most appropriate for their care. While it is clear which hospitals are best for stroke victims, it is very difficult politically to implement regionalization. When representatives from a hospital try to implement regionalization, it appears to be self-serving. Dr. Batjer suggested that an apolitical body is needed to lead implementation. Turning to research issues, Nick Jouriles, vice president of ACEP, said that an ACEP board member was recently turned down for an NIH grant, and the rejection letter stated the grant could not be awarded because the
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Future of Emergency Care: Dissemination Workshop Summaries principle investigator was an emergency physician. Dr. Jouriles disagreed with Dr. Hargarten’s earlier comment that emergency care stakeholders should focus on advocating for translational research support from NIH. Instead, he said there is a need for an independent institute for emergency medicine research at NIH. In response, Dr. Hargarten said that the award decision was singularly disappointing, but emergency medicine researchers have made progress at NIH. The translational research centers are currently being funded, and this source of funding should be pursued by emergency medicine researchers. Dr. Jouriles also noted that ACEP, with the support of the Emergency Nurses Association, developed the Access to Emergency Medicine Services Act (House Bill 3875 and Senate Bill 2750) and encouraged other groups, including the American College of Surgeons and the American Academy of Pediatrics (AAP) to support the legislation. One of the final comments was from Jeff Bates, an emergency physician at a level 4 trauma center in Texas, located 100 miles from the nearest level I trauma center. Dr. Bates described the plight of rural EDs with regard to critical workforce shortages. There are only three paramedics in his county, so most EMS patients are not served by a paramedic. Most of the nurses in his ED are licensed vocational nurses (LVNs) who have one year of training and no associate degree. Dr. Bates, an internal medicine physician by training, serves as the director of trauma because the hospital does not have a surgeon. He pointed out that there are four emergency medicine physician organizations with different agendas; some he cannot join because he is not residency-trained in emergency medicine. While there is only one emergency nursing organization, the LVNs cannot join it because they do not meet the training requirements. Dr. Bates emphasized several points. First, there should be increased focus on the emergency care challenges facing small and rural hospitals: 1 in 6 hospitals has 2,500 or fewer ED visits. Second, emergency providers need to collaborate and address core competencies for the workforce. Third, the United States simply does not have enough doctors. Calls to train more physicians in emergency medicine will simply pull from other specialties. An increase in the number of medical schools and training slots is needed. Luncheon Speaker Cortez Trotter, chief emergency officer for the city of Chicago, gave the luncheon address and commented on several of the challenges in the reports, noting their relevance to the city of Chicago. He said that, through its consortium of medical directors, the city is already addressing the IOM committee’s recommendation to improve coordination of emergency care services. Over the years, the EMS system in Chicago has matured and has
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Future of Emergency Care: Dissemination Workshop Summaries performed very well. But looking forward, Chief Trotter said that the city will continue to build on the integrated, computer-aided dispatch system that combines police, fire, EMS, and emergency management. Currently, paramedics can communicate in real time with hospitals, but more can be done. The city of Chicago and the state of Illinois are working collaboratively to develop more solutions to the types of challenges described in the IOM reports. Chief Trotter addressed the issue of funding, noting that, while Congress should devote more resources to EMS and hospital-based preparedness programs, stakeholders should not wait for Congress to act. There are strategies, such as Chicago’s life safety partnerships, that communities can undertake immediately. He also recommended looking locally for funding. In 2006, Chicago received $37 million from the Department of Homeland Security (DHS) Urban Area Securities Initiative, and it received similar levels of funding in previous years. But there are only so many things that the department can purchase with those funds each year. The latest technologies will make little difference if EMS personnel cannot unload patients at EDs because of overcrowding. Chief Trotter said that stakeholders have not approached him about emphasizing emergency medical services in funding requests to DHS. He also emphasized that emergency care providers need to bring attention to the work that they do to maximize funding opportunities. When the city of Chicago conducts preparedness drills, the media covers the event and the public recognizes that the city cares about preparedness and keeping its citizens safe. However, the hospital community and first responders tend to be too humble and do not promote themselves very well. Chief Trotter concluded by saying that the IOM reports represent a good starting point for stakeholders to come together in Chicago and address some of the issues collaboratively. He encouraged providers to take action and offered his assistance in improving the emergency care system. THE EMERGENCY CARE WORKFORCE The first afternoon session focused on the emergency care workforce. Four presentations on the workforce were followed by an open discussion. The session was moderated by IOM committee member Nels Sanddal. On-Call Specialists Bruce Browner, professor and Gray-Gossling chair and chairman emeritus of the Department of Orthopedic Surgery at the University of Connecticut, discussed on-call specialist workforce issues, particular those related to orthopedic surgeons and neurosurgeons. Many specialists are moving
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Future of Emergency Care: Dissemination Workshop Summaries away from taking call in EDs because of poor reimbursement, professional liability concerns, disruptions to elective practices, time away from family, occupational hazards, and the lack of staff and equipment available to specialists at night. Specialists are making individual decisions to stop providing care in the ED until these situations are rectified. While there is no formal boycott, the summation of all the individuals withdrawing from care results in a similar impact. Dr. Browner explained that the American Academy of Orthopedic Surgeons developed a position statement with recommendations that are similar to those in the IOM reports. The statement says that orthopedic surgeons have a responsibility to care for patients in their community and should collaborate with each other and local hospitals to determine how to meet the needs of patients. In addition, hospitals have a responsibility to ensure appropriate circumstances for the surgeons to work, and policy makers have a responsibility to solve the liability problem. Dr. Browner discussed the proposed development of acute care surgery, a new surgical practice program that has been proposed as a potential solution to the limited specialist availability problem. The original proposal generated considerable controversy because it called for the acute care surgeon to perform some selected neurosurgery and orthopedic surgery in the emergency care setting to improve patient access. Concerns were raised because of the limited training time acute care surgeons would have in those areas and that patient care would be compromised. In addition, Dr. Browner said that acute care surgeons would not be able to provide definitive care, so patient hand-offs would be necessary. He added that surgeons trained in acute care surgery may be no more likely to work in rural areas, where the absence of surgical specialists is felt strongest. According to Dr. Browner, a better solution is the one recommended in the IOM reports: regionalization. He also suggested the possibility of other strategies, such as allowing tax deductions for services for which specialists do not receive reimbursement, or federal reimbursement for liability costs, or both. Physician Supply Steven Krug, head of the Division of Emergency Medicine and associate chair for clinical affairs in the Department of Pediatrics at Children’s Memorial Hospital, spoke about the inadequate supply of health care providers, including qualified providers of emergency care. As early as the 1970s, a variety of oversight groups for graduate medical education and professional societies predicted that there would be a significant oversupply of physicians by the year 2000, particularly subspecialists. A variety of policy and funding decisions were developed to essentially halt further growth in
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Future of Emergency Care: Dissemination Workshop Summaries medical school enrollment and specialty training programs. However, the physician surplus was never realized, and today there is a shortage, particularly in subspecialty areas, including pediatric subspecialty areas. Most experts now predict a critical shortage of physicians by 2020, coincident with an aging population that will consume health care resources at a rate in excess of younger populations. An inadequate supply of physicians is likely to result in more people seeking care in EDs. Recognizing the problem, the IOM committee called for the Department of Health and Human Services (DHHS) and others to undertake a detailed assessment of emergency and trauma workforce capacity, trends, and future needs and to develop strategies to meet those needs. Also, in June the Association of American Medical Colleges issued a white paper calling for a 30 percent increase in medical school enrollment. Even if there is an immediate increase in medical school enrollment, it will take at least a decade for the effect to be felt, because of the lengthy training process. But simply increasing the number of medical students will not solve the problem, because approximately one-quarter of physicians in residency training today are trained internationally. Dr. Krug emphasized that an increase in both medical school enrollment and residency slots is necessary. Today the emergency care physician workforce is diverse in terms of disciplines and specialties, and this diversity is likely to continue. There are not enough emergency trained physicians to staff all EDs, and even fewer hospitals have access to pediatric emergency physicians. Dr. Krug highlighted several short-term solutions contained in the IOM reports, including having all health care certification bodies define emergency care competencies and require practitioners to receive the education and training needed to achieve those competencies; having EMS agencies and hospitals appoint pediatric emergency care coordinators to provide pediatric leadership for the organization; developing categorization systems for EMS, EDs, and trauma centers based on service capabilities; and linking rural hospitals with academic medical centers to enhance opportunities for consultation, telemedicine, patient referral and transport, and continuing education. The Illinois’ Emergency Medical Services for Children program has developed a hospital categorization system for pediatric emergency readiness. Hospitals can voluntarily achieve one of three levels: an emergency department approved for pediatrics (EDAP); a standby EDAP, which may not have 24/7 coverage with physicians; or a pediatric critical care center (PCCC), which is an EDAP with a pediatric intensive care unit. These hospitals agree to meet guidelines published jointly by AAP and ACEP in 2001 regarding clinical staff training and continuing education, standards for essential equipment supplies and medications, requirements for key policies and quality improvement, and the presence of clinical leadership. There are approximately 100 hospitals participating as of April 2006.
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Future of Emergency Care: Dissemination Workshop Summaries on EMS is that it does not give NHTSA enough credit for establishing EMS educational standards. However, only so much can be done at the federal level; now states should identify and accept responsibility for adopting EMS education standards. According to the IOM report, Emergency Medical Services at the Crossroads, “Educational program accreditation and national certification need to be in place before the transition from the national standard curriculum to the national EMS education standards can take place.” In other words, states must accept national certification and program accreditation before national standards can be implemented. The National Association of State EMS Officials has endorsed the EMS Education Agenda, with the condition that no definitive timetable would be set for implementation. Unless the states take action, according to Dr. Pirrallo, basic information on the EMS workforce will remain unknown. With national accreditation and certification, we will at least be able to answer some primary questions about retention and recruitment and be able to determine whether there is there a shortage of personnel or simply a maldistribution. A final EMS workforce recommendation from the IOM committee is for the American Board of Emergency Medicine to create a subspecialty certification in EMS. According to the report, “EMS systems should have highly involved and engaged medical directors who can help insure that EMS personnel are providing high-quality care based on current standards of evidence.” The National Association of EMS Physicians, the leading professional organization for EMS physicians, is making this recommendation a primary short-term initiative. Dr. Pirrallo noted that EMS is clearly part of a practice of medicine, and physician involvement is necessary. One common characteristic of all successful EMS systems is that they have an EMS physician leader behind the scenes. Dr. Pirrallo concluded by discussing funding. It is clear that most state EMS offices are underfunded. However, national accreditation of educational institutions and personnel certification, in the long run, may actually save money at the state level because state offices would no longer have to take responsibility for those functions. Open Discussion on Workforce Issues Several comments were made by attendees following the four presentations. Dr. Blum explained that ACEP will soon undertake a study of the emergency physician workforce. He then inquired whether a lack of faculty is a key barrier to the training of nurses and EMTs. Dr. Kunz Howard agreed faculty shortage is the primary problem with the training of nurses, and 150,000 to 160,000 qualified applicants were turned away from nursing school in the previous year because of a lack of faculty. Dr. Pirrallo
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Future of Emergency Care: Dissemination Workshop Summaries noted that variability in EMS faculty qualifications is a greater problem in the training of the EMS workforce than faculty shortages. Dr. Willoughby DeJesus noted that there has been EMS subspecialty certification available to osteopathic emergency physicians for approximately 10 years. However, many physicians who serve as EMS medical directors are not compensated for that role. Mr. Sanddal noted that quality medical direction and oversight are essential to the quality of prehospital care and that physicians should be recognized and compensated for their participation. Michael Hansen from the Illinois Fire Chiefs Association said that the state of Illinois tried to implement the national registry (i.e., national certification) three times but failed each time. The organization has concerns about cost of the exam, pass rates, and how the exam is written. Mr. Sanddal clarified that the recommendation in the IOM report says that states should accept national certification as a basis for state licensure; it does not mandate national certification. Dr. Batjer noted that the American Board of Neurological Surgery is considering the creation of several curricula in neurosurgical training programs, one of which would be abbreviated and would focus on emergency care, particularly trauma care for the brain and the spine. This new curricula could result in greater numbers of practitioners delivering care in the ED. Dr. Krug raised concerns about whether these practitioners would be qualified to provide care to children. Dr. Sasson said that the Emergency Medicine Resident’s Association (EMRA) agrees with the IOM committee’s recommendation that subspecialty certification in EMS should be awarded. EMRA also supports critical care certification fellowships for emergency medicine residents, noting the shortage of intensivists projected in the future. Many emergency medicine residents would like to receive critical care certification, but the internal medicine critical care fellowship slots are closed to emergency medicine residents. Scott Altman, an emergency physician practicing in Chicago, added that, with the shortage of practitioners expected in the future, there is a need to think about new ways to distribute human resources by separating technical and cognitive personnel. With improvement in communications technology, it may be possible to have a few highly skilled cognitive specialists in a particular medical field linked to many technicians in the field who can implement the decisions made by the cognitive specialists remotely. Dr. Krug agreed, but said that all physicians must have some basic competency skills to practice. Carey Chisholm from the Society of Academic Emergency Medicine concluded the open discussion session by noting that residency training slots, in addition to medical school classes, need to expand in order to ad-
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Future of Emergency Care: Dissemination Workshop Summaries dress the physician shortage; however, residency slots will not increase unless federal caps on funding are removed. He also noted the need to develop more academic departments of emergency medicine across the country. HOSPITAL EFFICIENCY The second afternoon session focused on hospital efficiency and technology. Four presentations were followed by an open discussion. The session was moderated by IOM committee member Brent Asplin. Response from the Joint Commission on Accreditation of Healthcare Organizations Peter Angood, vice president and chief patient safety officer at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) spoke about its standards related to emergency services. He began by saying that JCAHO generally supports the recommendations from the IOM reports; however, some clarification is needed around the IOM committee’s recommendation for JCAHO to reinstate strong standards for ED boarding and diversion. When JCAHO develops standards, it puts the information on those standards out on an Internet-based survey tool, which facilitates the field review process. This is JCAHO’s way of obtaining direct feedback on the practicality and feasibility of the recommendations. During the field review related to boarding and diversion, JCAHO received an incredible amount of negative feedback about developing standards in those areas. As a result, it focused its efforts on a “comparable standards of care” standard, which says that hospital leaders must identify and mitigate impediments to efficient patient flow through the hospital, and that they should maintain comparable standards of care regardless of where a patient is located. The Joint Commission used to have a three-year survey review process; when the surveys took place, there was rarely a boarded patient in the ED. However, it is now moving to an unannounced survey process, and they expect to collect more information regarding the problem of boarding in EDs. A key component of the comparable standards of care standard addresses the needs of admitted patients who are in temporary bed locations awaiting an inpatient bed. Twelve key elements of care were identified by JCAHO and are used in the survey process to evaluate hospitals on this standard. These 12 elements focus on ensuring adequate and appropriate care for patients. They have implications across the hospital organization and should be considered by hospital leaders when planning care and services to the patients. The elements include patient privacy and confidential-
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Future of Emergency Care: Dissemination Workshop Summaries ity, proper technology and equipment to meet patient needs, appropriate practitioners to provide patient care beyond immediate emergency services, and assurance of communication among all health care providers. Dr. Angood also mentioned that JCAHO held a roundtable on emergency services in 2003-2004. A white paper, which summarizes the findings from that roundtable, is under development. The white paper will discuss managing demand and improving supply of emergency services, protecting patients, and aligning regulation and financial incentives to promote access. Dr. Angood concluded by stating that JCAHO will be convening a meeting in early 2007 of hospital-based physician organizations to address in-hospital care, including emergency care. The meeting will focus on getting physicians involved in helping hospitals improve their overall functioning. Improving Efficiency Through Technology John T. Finnell, director of the Informatics Division in Emergency Medicine at Wishard Memorial Hospital, discussed two initiatives under way in Indiana to improve the efficiency of care through information technology. In most areas of the country, the health care system fragments patient information and creates redundant, inefficient efforts. The system in Indiana, and the systems of the future, will consolidate information and provide a foundation for unifying efforts. The Indiana Network for Patient Care (INPC) is an operational, sustainable community-wide health information exchange in Indianapolis that receives patient information from all local medical/surgical hospitals, physician offices, community health centers, city and state health departments, labs, pharmacies, and others. The INPC contains information on hospital discharge summaries, ED and other outpatient visits, inpatient and outpatient lab results, immunizations, operative notes, radiology reports, path reports, medication lists, and more. This information is readily available in seconds to ED staff when a patient enters the ED. The INPC contains deidentified patient data covering 30 years that are available for clinical research. Recently, researchers at the Regenstreif Institute used the data to examine ED use. They found that a subset of patients visited all five hospital systems in Indianapolis within one year. About 40 percent of ED patients at any particular hospital system have data in other hospital systems, too. Because all five systems are connected to the INPC, the system captured data on all of those visits. Dr. Finnell also discussed the Public Health Emergency Surveillance System (PHESS) in Indiana. Its goal is to connect all 114 EDs in the state over the next four years. Currently there are 67 connected hospitals cover-
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Future of Emergency Care: Dissemination Workshop Summaries ing 5,500 ED visits per day. Information from the PHESS is used by the state for electronic surveillance, and the system is capable of detecting outbreaks that individual EDs cannot. For example, data from the PHESS revealed a spike in gastrointestinal cases that led to an investigation by the state health department. The state was able to trace the outbreak to certain products being sold at a local ethnic food grocery store, and the threat was eliminated. Dr. Finnell concluded by identifying several factors that can contribute to the success of similar projects. First, if there are already information feeds in a hospital, the hospital should use them. It may be very easy to capture the data. Second, a neutral convener, such as the Regenstrief Institute, which is not a health care organization, is needed to lead the project. Health care organizations participate voluntarily, and their servers are separate from the servers in every other system. Organizations have the freedom to withdraw from the system at any time. Third, organizations should proceed incrementally. Finally, the systems described above are based on the establishment of standards. It is important to develop flexible, standards-based infrastructures that can integrate an array of diverse clinical data. Improving Patient Flow Linda Kosnik, chief nursing officer at Overlook Hospital, spoke about demand to capacity management, particularly with regard to surge capacity for overcrowding and disaster planning. Increased resources are often necessary to address these issues, but often simply moving the right resources to the right place at the right time will be of great benefit. Ms. Kosnik described the elements needed to match demand to capacity. First, institutional memory and structured communication are necessary to ensure that the plans that were developed in advance are implemented at the time when they are needed most. Communication cannot wait until a disaster occurs; planning must be done in advance. It also requires demand to be visible and predictable. Direction and information need to be provided to individuals at the moment of stress. Those involved need to understand exactly what must be done to mitigate each specific situation, and in order to accomplish that, the individuals closest to the situation need to be empowered and held accountable. Hospital administrators cannot simply solve problems for those closest to the situation; they need to participate. Ms. Kosnik emphasized the need for data, noting that one cannot make improvements in the absence of data. She provided an overview of the information system at Overlook Hospital that tracks demand, capacity, and interventions with real-time data. Using color coding, the system indicates whether demand is matched to capacity (indicated by a green signal) or whether demand on the system is escalating (signals change from yellow to
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Future of Emergency Care: Dissemination Workshop Summaries red) in various units of the hospital. The system also allows for an overview of demand on the system, which is measured by census and acuity. In addition, the system tracks capacity, including equipment and processes, as well as support services and staff. Most critical, the system shows interventions or solutions that can be implemented as demand exceeds capacity. When one of the interventions is implemented, alerts are sent to staff pagers as well as to printers on various units, to make sure that those interventions occur consistently. The interventions provide direction in terms of who should act, what should be done, and where. The system has done much to reduce diversion at Overlook Hospital. When the system was implemented 10 years ago, the hospital went on diversion every week for multiple days in a row. After implementation, diversion soon dropped to five times per year. Overlook Hospital also uses the system for emergency preparedness planning. Should a disaster occur, the system will notify all appropriate individuals and stakeholders with instructions on what they need to do, when they need to do it, and where they need to be at different times. A pandemic alert (a drill) was triggered through the system, and messages were sent to multiple pagers, including various organizations in the community, such as first aid squads, the fire department, and the police department. They are automatically asked to come to the hospital, which saves hospital staff the task of making multiple phone calls and ensures that everyone receives information at the same time. Improving Hospital Quality and Efficiency Susan Nedza, chief medical officer for Region V, Centers for Medicaid and Medicare Services (CMS), began her remarks by highlighting two assumptions made in the IOM reports. First, the reports state that emergency care providers and advocates can do little to alter environmental factors, such as increasing utilization of the ED by the uninsured, the increasing age and number of chronic conditions of patients, staffing shortages, malpractice insurance rates, declining public and private reimbursement, and disasters. She noted that there is an opportunity to move beyond thinking about EDs as passive receptors and that addressing demand issues is an essential leadership task for ED providers and health system leaders. Hospitals in the United States are currently undergoing one of the largest expansions in facilities since the Hill-Burton Act of 1946, but expansions will not be enough to solve the problem. The demand issues must be addressed. Addressing patient demand will require coordination with other components of the system, including long-term care facilities, federally qualified health centers, primary care physicians, and others. Coordinating with primary care providers to share patient records and improve chronic care
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Future of Emergency Care: Dissemination Workshop Summaries will be critical. It is also essential to address the availability of substance abuse and mental health services to reduce the number of patients who make frequent visits to the ED. A second assumption made in the IOM reports is that it is the role of the hospital chief executive officer (CEO) to address efficiency. However, the CEO is appointed with the approval of the hospital’s board of directors, so the board needs to make efficiency a priority. It will also require physician leadership and coordination beyond the doors of the hospital. But expecting hospital leadership to undertake efforts that are not in alignment with the hospital’s financial interests or market share is unrealistic. Working with hospital systems locally and at the federal level will be imperative, so linkages between the American Hospital Association and ACEP are critical. Emergency care providers typically speak about efficiency in terms of process; however, payers think about efficiency in terms of cost: the highest level of quality that can be achieved for the lowest cost. Efficiency cannot be separated from resource allocation decisions. EDs are resource allocation centers that make such decisions as calling consults, allocation of intensive care unit beds, where patients are sent after discharge, and whether imaging is used. ED crowding and on-call specialty issues may be addressed by pay for performance and a payment system based on episodes of care. As a patient moves through the EMS system, the ED, the catheterization lab, or other units, care would be coordinated throughout the entire process. In the end, the hospital and physicians would be aligned not only in providing quality care based on quality measures, but also efficient and cost-effective care. There would be a greater incentive for proper resource allocation. Hospitals may also be inclined to consider different ways to secure on-call specialists, such as regionalization and the development of virtual networks, if payment is based on episodes of care. Dr. Nedza provided a list of the major categories that payers are considering for episode of care payments, and they include the top 20 ED diagnosis-related groups. Changing payment to episodes of care will change how care is delivered in the ED because it reengineers how hospital leaders view efficiency. Dr. Nedza added that, in the future, Medicare will focus on value-based purchasing. It will involve evaluating the value of the ED in providing access to the community, managing acute episodes of care, managing chronic disease, and prevention. In conclusion, Dr. Nedza noted that improving efficiency will need to be done locally. The CMS is not going to fix the problems, but it will implement payment policies and regulatory policies that will set some direction. Transforming the system will involve addressing both supply and demand for services.
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Future of Emergency Care: Dissemination Workshop Summaries Open Discussion on Efficiency During the open discussion session, there were many questions and comments about JCAHO’s standards. Dr. Blum described a recent survey in which 70 percent of ED directors reported boarding patients in the ED almost every week of the year. He asked why more attention is not given to the problem of boarding by JCAHO and CMS. Dr. Angood responded, saying that JCAHO’s strategy has been to promulgate an equal standard of care for all patients, regardless of location. There is an expectation that hospitals will look into their processes of care and develop solutions. Although ED boarding is rarely seen by auditors when visiting hospitals, they are not blind to the fact that it occurs. The problem is likely to become more apparent as JCAHO moves to a process of unannounced visits. Dr. Nedza added that nothing precludes ED providers from reporting their hospital to the state survey process for being out of compliance with Medicare’s conditions of participation. Although CMS receives many reports of quality problems, patient boarding in the ED is rarely reported. If the state surveyors give a 28-day warning to a hospital that Medicare reimbursement will be terminated because of lapses in quality of care, a hospital’s board is going to get involved. Debra Livingston from Northwestern University added that the equal standard of care goal creates a burden on ED staff to figure out how to give the same standard of care to patients boarding in hallways. Another member of the audience noted that most physicians, nurses, and EMTs are not familiar with JCAHO’s standards. He encouraged JCAHO to educate physicians on a regular basis on its standards, and that academic institutions make the standards a part of their core curriculum. Brenda Staffan from Rural/Metro Medical Services said that ambulance providers have been using flexible deployment (often called system status management), matching the supply and deployment of ambulance resources with demand, for nearly 20 years. This is a best practice model for collecting information about call volume and using computer-aided dispatch systems to deploy ambulances. She also added that ED overcrowding often results in very long off-load times for ambulances and local EMS systems must be included in discussions with hospitals, state regulators, local health departments, and others about how to address ED crowding. Dr. Asplin asked the panelists to identify the one or two key things that the industry (providers, hospitals, EMS agencies) can do to implement the IOM committee’s vision for the future of emergency care. Dr. Finnell responded that delivering information to providers at the time of care can ultimately reduce costs a great deal. Dr. Nedza added that the systems that have been best able to address the problems described in the IOM reports
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Future of Emergency Care: Dissemination Workshop Summaries are those that identify a competitive advantage or economic benefit from doing so. Harry “Tripp” Wingate from the United States Alliance of Emergency Medicine asked about progress implementing pay for performance in Medicare. Dr. Nedza noted there have been a number of hospital quality measures developed to date, and there will be more to come. Also, a group demonstration project is under way that uses financial bonuses to reward hospitals for their performance in certain clinical areas. Some data from the project are available, and they indicate five areas in which hospital efficiency and quality measurement have improved quality and decreased cost. Finally, Dr. McKibben mentioned the Patient Safety Improvement Act and how it might be used for reporting problems of boarding and patient safety. Dr. Angood explained that the act creates patient safety organizations (PSOs) that will collect and analyze confidential information reported by providers regarding errors or lapses in quality. The PSOs will then report the information to the Agency for Healthcare Research and Quality (AHRQ). Currently, reporting is limited due to fear of discovery or liability concerns. The act provides federal legal privilege and confidentiality protections for the information reported. The PSOs have not yet been implemented. AHRQ is the lead agency, and it is currently developing regulations for the program. The unanswered question that remains is whether providers have an incentive to report. LESSONS LEARNED FROM TRAUMA SYSTEM DEVELOPMENT The keynote address was provided by J. Wayne Meredith, chief of surgery at Wake Forest University, Baptist Medical Center, and director of trauma for the American College of Surgeons. Dr. Meredith was asked to address lessons learned from trauma system development, and how they could be applied to the development of a coordinated, regionalized, and accountable emergency care system. He began his presentation by describing the research showing that trauma centers and trauma systems save lives. Between 1992 and 2002, Canada implemented a coordinated, regionalized, accountable system of trauma care that resulted in a dramatic decline in the mortality rate per population per vehicle mile driven. A study by Avery Nathens found that trauma systems are nearly as effective as mandatory, primary restraint laws in states, and more effective than secondary restraint laws, in terms of saving lives, per vehicle mile driven. And a recent study by Ellen MacKenzie found a 25 percent reduction in mortality among seriously injured patients when care was provided at a trauma center versus a nontrauma center. However, studies also indicate that of seriously injured patients, 40 percent are not treated in a trauma center.
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Future of Emergency Care: Dissemination Workshop Summaries Dr. Meredith provided an overview of the basic steps for building a coordinated, regionalized, accountable system. They include educating and building legislative and public support, conducting a needs assessment that links to prevention, developing enabling legislation, developing a comprehensive trauma plan, creating oversight structure, adopting operational standards, initiating a performance improvement plan, and conducting periodic external reassessments of the system. In addition to the basic steps for building a system, Dr. Meredith shared lessons learned from trauma system development that must be considered for development of emergency care systems. Most importantly, systems must be inclusive and developed by individuals with multidisciplinary expertise. Exclusive systems are designed to provide the best care to the sickest patients; inclusive systems cover the care of all patients. If an initiative to regionalize ischemic heart disease were developed, for example, it should include the care of all patients, not just those with cardiogenic shock or ischemic myocardial infarction. He also described several other lessons learned. First, planners must define resources needed for optimal care and ensure that hospitals have those resources in place. Severely ill patients do not choose where they receive care; public policy dictates where they should be treated. Those hospitals must be prepared. Second, information systems are essential. The National Trauma Databank serves as the information system for trauma; NEMSIS or the INPC in Indianapolis may serve a similar role. Information supports utilization review, prevention efforts, and research. Third, there must also be more evidence-based medicine in trauma and emergency care. Emergency care research has been the orphan of the scientific health care community for decades. Outcome benchmarks for disease processes must be developed. Fourth, much has been learned from the Trauma Systems Consultation Committee, a multidisciplinary team that conducts compressive on-site trauma system reviews, from developing the evaluation document and making site visits to systems. Dr. Meredith emphasized the collaborative, multidisciplinary nature of the committee. Fifth, regionalization does not mean centralization. Regionalization does not mean that one hospital is responsible for all trauma care or all emergency care. In an inclusive system, all providers participate and understand their responsibilities. Centralization (as opposed to regionalization) results in adverse selection, poor utilization of resources, overwhelmed hospitals, delays in treatment for some injuries, and diminished surge capacity. Finally, it is essential to assemble all the stakeholders to discuss publicly the structure of the system. Stakeholders must be respectful, honest about their concerns, and willing to listen to other points of view. It is also essential to start and end the conversation by discussing patient needs. For
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Future of Emergency Care: Dissemination Workshop Summaries example, is the system designed to ensure that centers have access to the patients they need? Or is the system designed to ensure that patients have access to the centers that they need? Dr. Meredith concluded his presentation by discussing the disappointing lack of support provided by policy makers to improve emergency and trauma care. Policy makers have not received a simple, concise, and consistent message from emergency and trauma leaders. Every time stakeholders meet with federal policy makers, they tell a slightly different story; as a result, policy makers do not know how to help. He emphasized the need to create a simple, concise, and consistent message about emergency and trauma care that all stakeholders can convey to policy makers. CLOSING To close the meeting, Dr. Eastman thanked the presenters for their remarks and members of the audience for their enthusiasm and participation. He also reiterated a point made by Dr. Meredith that stakeholders must always keep the best interest of patients in mind when planning reforms to the emergency care system.
Representative terms from entire chapter: