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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Appendix C Federal Response to 2006 IOM Recommendations TABLE C-1 Federal Response to 2006 IOM Recommendations Rec # (Report) IOM Recommendation Federal Response 2.1 (ED) Congress should establish dedicated funding, separate from Disproportionate Share Hospital (DSH) payments, to reimburse hospitals that provide significant amounts of uncompensated emergency and trauma care for the financial losses incurred by providing those services. Congress has taken up a number of related bills in the last two years, three of which were passed, but they targeted only two states (Tennessee and Hawaii). Overall this recommendation has gone unanswered. (Handrigan) a. Congress should initially appropriate $50 million for the purpose, to be administered by the CMS. b. CMS should establish a working group to determine the allocation of these funds, which should be targeted to providers and localities at greatest risk; the working group should then determine funding needs for subsequent years.
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 3.1 (All) HHS and NHTSA, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop an evidence-based categorization system for emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities. Some states (CA, IL, OK, TN) have voluntary designations that hospitals can seek. Illinois and California designate emergency departments approved for pediatrics; Oklahoma and Tennessee give pediatric medical recognition. This may signify the presence of a pediatric emergency coordinator, for example. (Kavanaugh) 3.2 (All) NHTSA, 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, including children. NHTSA, with FICEMS and NEMSAC, is creating an evidence-based guideline development process that will be dynamic rather than static and will keep pace with the changing nature of EMS best practices. (See Chapter 1.) (Dawson) 3.3 (All) HHS should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance. The ECCC has convened a new entity called the Council on Emergency Care which brings together partners from throughout government at all levels, with diverse subject matter expertise, to coordinate the entire federal emergency care agenda, but also to examine indicators of performance. (Handrigan) NHTSA has partnered with the EMS community in conducting the Performance Measurement Project, which will recommend indicators of quality emergency medical services and system performance. This project will soon be final. (Dawson) 3.4 (ED) HHS should adopt regulatory changes to EMTALA and HIPAA so that the original goals of the laws will be preserved, but integrated systems can be further developed. CMS convened a technical advisory group in 2006. They issued a series of recommendations which have contributed to the progress of legislation that is now in committee. (Handrigan)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 3.4 (EMS) (Peds) Congress should establish a demonstration program, administered by the HRSA, to promote coordinated, regionalized, and accountable emergency care systems throughout the country, and appropriate $88 million over 5 years to this program. Congress has not yet provided the $88 million needed to fund the trauma system. However, there is now a bill in Congress that would help stabilize the trauma system. In addition, in May 2009 the ECCC, in conjunction with FICEMS and other federal partners, held a town hall meeting at the Society for Academic Emergency Medicine. IOM will also be conducting a workshop on regionalization in September 2009. ECCC also plans to create several demonstration projects focused specifically on regionalization in 2010. So this is moving forward. (Handrigan) NHTSA and NEMSAC have produced model legislation focusing on regional EMS systems. This will be reflected in DOT’s revised highway safety standards that serve as a basis for assessing state EMS systems. (Dawson) 3.5 (ED) Same as 3.4 (EMS) above Regional demonstrations ($88 million) 3.5 (EMS) Same as 3.6 (ED) below Federal lead agency 3.5 (Peds) Same as 3.4 (ED) above EMTALA and HIPAA
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 3.6 (ED) (Peds) Congress should establish a lead agency for emergency and trauma care within two years of the release of this report. The lead agency should be housed in HHS, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. The Emergency Care Coordination Center (ECCC) charter was signed in January 2009. ECCC is an infant organization, but this is the federal answer to the IOM recommendation. The primary mission of the ECCC is to support the USG’s coordination of in-hospital emergency medical care activities and to promote programs and resources that improve the delivery of our nation’s daily emergency medical care and emergency behavioral health care. (Handrigan) 3.6 (EMS) Same as 3.4 (ED) above EMTALA and HIPAA 3.7 (EMS) CMS should 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. This recommendation is directed to CMS. However, NEMSAC has requested, through FICEMS, that CMS establish this working group. Also, NEMSAC is completing a white paper that addresses EMS financing. (Dawson) 3.7 (Peds) Congress should appropriate $37.5 million per year for the next 5 years to the EMS-C program. Recommendation not directed to the federal partners. 4.1 (ED) CMS should remove the current restrictions on the medical conditions that are eligible for separate clinical decision unit (CDU) payment. This issue has not been addressed, but is worthy of consideration by CMS. (Handrigan)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 4.1 (EMS) State governments should adopt a common scope of practice for emergency medical services personnel, with state licensing reciprocity. The National EMS Scope of Practice Model was completed several years ago. It now serves as the basis for the National EMS Education Standards. The National Association of State EMS Officials (NASEMSO), through a cooperative agreement with NHTSA, is assisting in promoting implementation. Currently, 39 states have adopted or plan to adopt the scope of practice model. (Dawson) 4.1 (Peds) Every pediatric- and emergency care-related health professional credentialing and certification body should define pediatric emergency care competencies and require practitioners to receive the level of initial and continuing education necessary to achieve and maintain those competencies. Recommendation not directed to the federal partners. 4.2 (ED) Hospital CEOs should adopt enterprisewide operations management and related strategies to improve the quality and efficiency of emergency care. Recommendation not directed to the federal partners. 4.2 (EMS) States should require national accreditation of paramedic education programs. Although progress has been slow, the National Registry of Emergency Medical Technicians (NREMT) has made a decision to require paramedic students to graduate from an accredited paramedic educational program by the year 2013. The National Association of State EMS Officials is working with the Committee on Accreditation of EMS Programs (CoAEMSP) to ensure that this will happen. Twelve states currently require paramedic education program accreditation. (Dawson)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 4.2 (Peds) HHS should collaborate with professional organizations to convene a panel of individuals with multidisciplinary expertise to develop, evaluate, and update clinical practice guidelines and standards of care for pediatric emergency care. As the IOM report noted, unless there is a commitment to funding pediatric emergency medicine research, there won’t be an adequate evidence base from which to derive the practice guidelines. Recently, EMS-C funding has been directed more toward activities that would improve the evidence base rather than guideline development specifically. However, EMS-C has provided some funds toward NHTSA’s evidence-based guidelines development process. (Kavanaugh) 4.3 (ED) Training in operations management and related approaches should be promoted by professional associations; accrediting organizations, such as the JCAHO and the NCQA; and educational institutions that provide training in clinical, health care management, and public health disciplines. Recommendation not directed to the federal partners. 4.3 (EMS) States should accept national certification as a prerequisite for state licensure and local credentialing of emergency medical services providers. NASEMSO is tracking progress on this recommendation. As of May 2008, 45 states use NREMT certification for licensure of at least one level of EMS provider. However, state requirements still vary considerably. (Dawson) 4.4 (EMS) ABEM should create a subspecialty certification in emergency services. Recommendation not directed to the federal partners. 4.5 (ED) Hospitals should end the practices of boarding patients in the emergency department and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. CMS should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures and incentives for implementation, monitoring, and enforcement of these standards. The first part of this recommendation is directed to hospitals. However, the second part, relating to the working group, is now being considered by Congress. The Access to Emergency Medical Services Act would convene a bipartisan commission to evaluate and recommend a path forward. (Handrigan)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 5.1 (ED) Hospitals should adopt robust information and communications systems to improve the safety and quality of emergency care and enhance hospital efficiency. This recommendation is directed to the hospitals; however, the federal government has provided significant momentum through the stimulus funds and the overall health IT strategy. (Handrigan) 5.1 (EMS) States should assume regulatory oversight of the medical aspects of air medical services, including communications, dispatch, and transport protocols. There are several bills in Congressional committees that would provide states with additional oversight responsibilities for air medical services. The National Transportation Safety Board (NTSB) also held a 4-day hearing on the topic in early 2009 and was scheduled to present a status report to FICEMS in June 2009. (Dawson) 5.1 (Peds) HHS should fund studies on the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety. A number of studies are currently under way. For example, PECARN is conducting a study examining the safety and efficacy of Lorazepam and diazapem in treating pediatric status epilepticus. Also, in April 2009, NICHD updated its priority list of needs and pediatric therapeutics. Some of what is currently under study or proposed for study include ketamine for sedation and hydroxyurea for sickle cell disease. (Kavanaugh) 5.2 (EMS) Hospitals, trauma centers, emergency medical services agencies, public safety departments, emergency management offices, and public health agencies should develop integrated and interoperable communications and data systems. DOT has completed the Next Generation 9-1-1 (NG-9-1-1) project, and has a national systems architecture for looking at more digital based communication systems able to transmit digital data (e.g., telematics) from the caller to first responders. (Dawson) See also Recommendation 5.3 (EMS) below.
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 5.2 (Peds) HHS and the NHTSA should fund the development of medication dosage guidelines, formulations, labeling, and administration techniques for the emergency care setting to maximize effectiveness and safety for infants, children, and adolescents. Emergency medical services agencies and hospitals should incorporate these guidelines, formulations, and techniques into practice. HHS and NHTSA are funding the development of medication dosage guidelines, formulations, labeling and administration techniques for the emergency care setting, and federal agencies and private industry are funding research on pediatric style technologies and equipment used by emergency care and trauma personnel. Also, the EMS-C National Resource Center, Duke University, and the American Academy of Pediatrics sponsored a meeting to discuss and prioritize ways to safely administer pediatric medication in emergency settings. (Kavanaugh) 5.3 (EMS) HHS should be fully involved in prehospital EMS leadership in discussions about the design, deployment, and financing of the National Health Information Infrastructure. The National EMS Information System (NEMSIS) and the national common data standard are now going through the HL-7 standardization development process so they will be in sync with health information technology and electronic health records. Information on NEMSIS is available at www.nemsis.org. (Dawson) 5.3 (Peds) Hospitals and EMS agencies should implement evidence-based approaches to reducing errors in emergency and trauma care for children. Recommendation not directed to the federal partners.
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 5.4 (Peds) Federal agencies and private industry should fund research on pediatric-specific technologies and equipment used by emergency and trauma care personnel. In February 2009, the National Center for Research Resources at NIH held a meeting on pediatric drug and medical device development. The meeting highlighted the insufficient and fragmented infrastructure for pediatric clinical drug trials and device development. Discussions surrounded use of clinical research infrastructure, provided through CTSAs, to develop effective partnerships to develop drugs and medical devices that meet the needs of children, including those that are most likely to be used by emergency care personnel. (Kavanaugh) 6.1 (ED) Hospitals, physician organizations, and public health agencies should collaborate to regionalize critical specialty care on-call services. This is a contentious issue. CMS has initiated a community on-call system to allow communities to develop on-call lists. This allows hospitals to continue to function within target guidelines, but it is arguable whether it is an adequate solution to the problem. (Handrigan) 6.1 (EMS) HHS, NHTSA, and DHS, and states should elevate emergency and trauma care to a position of parity with other public safety entities in disaster planning and operations. Since the IOM report, there has been considerably increased activity with respect to EMS at the Federal level. The Office of Health Affairs (OHA) was created in DHS; the Emergency Care Coordination Center (ECCC) was established in HHS; and FICEMS also has a Preparedness Committee. (Dawson)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 6.1 (Peds) Federal agencies (HHS, NHTSA, and DHS), in partnership with state and regional planning bodies and emergency care providers, should convene a panel with multidisciplinary expertise to develop strategies for addressing pediatric needs in the event of a disaster. This effort should encompass the following: Development of strategies to minimize parent–child separation and improved methods for reuniting separated children with their families. Development of strategies to improve the level of pediatric expertise on disaster medical assistance teams and other organized disaster response teams. Development of disaster plans that address pediatric surge capacity for both injured and non-injured children. Development of and improved access to specific medical and mental health therapies, as well as social services, for children in the event of a disaster. Development of policies to ensure that disaster drills include a pediatric mass casualty incident at least once every 2 years. The Federal Emergency Management Agency (FEMA) operates the national emergency family registry and locator system to facilitate reunification of families separated after a major disaster. HHS has this information in the locations it provides disaster response services. The EMS-C program is also funding a system to capture and process digital images of disaster victims who enter disaster response facilities. This will enable parents to view retrieved images to identify their missing children. Other federal activities and capacity include the Integrated Medical Public Health Preparedness and Response Training Summit; AHRQ’s “Pediatric Hospital Surge Capacity and Public Health Emergencies” report; the FEMA Crisis Counseling and Training and Assistance Program; the EMS-C National Resource Center’s informational toolbox on pediatric disaster preparedness, the National Commission on Children and Disasters; the Pediatric Disaster Resource and Training Center in Los Angeles; The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Child Traumatic Stress Network, and the HHS National Disaster Pediatric Medical Team. (Kavanaugh) 6.2 (ED) Congress should appoint a commission to examine the impact of medical malpractice lawsuits on the declining availability of providers in high-risk emergency and trauma care specialties, and to recommend appropriate state and federal actions to mitigate the adverse impact of these lawsuits and ensure quality of care. This is the intent of the Access to Emergency Medical Services Act. (Handrigan)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 6.2 (EMS) Congress should substantially increase funding for EMS-related disaster preparedness through dedicated funding streams. N/A 6.3 (ED) The American Board of Medical Specialties and its constituent boards should extend eligibility for certification in critical care medicine to all acute care and primary care physicians who complete an accredited critical care fellowship program. Recommendation not directed to the federal partners. 6.4 (ED) Professional training, continuing education, and credentialing and certification programs for all the relevant professional categories of EMS personnel should incorporate disaster preparedness into their curricula and require the maintenance of competency in these skills. Disaster preparedness is included in the National EMS Education Standards. These have also been synchronized with NIMS through the national emergency responder credentialing process. So the entire EMS Education Agenda for the Future and NIMS are linked together. (Dawson) 6.5 (ED) HHS, DOT, and DHS should jointly undertake a detailed assessment of emergency and trauma workforce capacity, trends, and future needs, and develop strategies to meet these needs in the future. A detailed assessment of the emergency and trauma workforce has not yet been done, however the ECCC and FICEMS are now in an ideal position to take this on. (Handrigan) In June 2008, NHTSA, in partnership with HRSA, published EMS Workforce for the 21st Century: A National Assessment. The assessment describes the national EMS workforce, while also elucidating the absence of consistent, nationwide EMS workforce data. The assessment is being used to guide development of the EMS Workforce Agenda for the Future. (Dawson)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 6.6 (ED) HHS, in partnership with professional organizations, should develop national standards for core competencies applicable to physicians, nurses, and other key emergency and trauma professionals, using a national, evidence-based, multidisciplinary process. Multiple stakeholders are required to execute this broad recommendation. HHS established the Federal Education and Training Interagency Group (FETIG), which acts as the board of directors for the new National Center for Disaster Medicine at Uniformed Services University of the Health Sciences (USUHS) and will help define a core curriculum relating to disaster preparedness. Using quality measures, the group is developing and improving core competencies. More work remains to be done. (Handrigan) 6.6 (ED) States should link rural hospitals with academic health centers to enhance opportunities for professional consultation, telemedicine, patient referral and transport, and continuing professional education. This issue relates to regionalization. There is great interest in this topic at the federal level and we intend to partner with our non-federal stakeholders on it. The recommendation was directed at the states and we will leave it to the states and the hospitals to address it specifically. (Handrigan) 7.1 (ED) DHS, HHS, DOT, and the states should collaborate with the Veterans Health Administration to integrate the VHA into civilian disaster planning and management. Through Homeland Security Presidential Directive (HSPD)-21, the Department of Veterans Affairs (VA) has been substantially and increasingly engaged in preparedness activities both at the federal and local levels. There has been great progress on this recommendation. (Handrigan) 7.1 (EMS) Federal agencies that fund research and trauma care research should target additional funding at prehospital EMS research, with an emphasis on systems and outcomes research. PECARN is developing research partnerships with two EMS agencies. They have completed a descriptive study of the EMS pediatric population within PECARN, and they encourage the involvement of prehospital EMS in the Research Network. NEMSIS will aid researchers tremendously by making standardized data available. (Dawson) 7.1 (Peds) See 8.2 (ED) below Research gaps and opportunities
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 7.2 (ED) All institutions responsible for the training, continuing education, credentialing and certification of professionals involved in emergency care (including medicine, nursing, emergency medical services, allied health, public health, and hospital administration) should incorporate disaster preparedness training into their curricula and competency criteria. The Federal Education and Training Interagency Group (FETIG) and the national center have taken this on and we are moving forward. (Handrigan) 7.2 (EMS) See 8.4 (ED) below Federalwide Assurance (FWA) Program 7.2 (Peds) Administrators of state and national trauma registries should include standard pediatric-specific data elements and provide the data to the National Trauma Data Bank. Additionally, the American College of Surgeons should establish a multidisciplinary pediatric specialty committee to continuously evaluate pediatric-specific data elements for the National Trauma Data Bank and identify areas for pediatric research. The EMS-C program supports the National EMS-C Data Analysis Resource Center (NEDARC), which helps EMS-C grantees and state EMS offices refine their capabilities to perform EMS research and optimize the delivery of emergency and trauma care. Specifically, the staff at NEDARC provides guidance on formatting, interpreting, and displaying data. (Kavanaugh) 7.3 (ED) Congress should significantly increase total preparedness funding in fiscal year 2007 for hospital emergency preparedness in the following areas: strengthening and sustaining trauma care systems; enhancing emergency department, trauma center, and inpatient surge capacity; improving emergency medical services’ response to explosives; designing evidence-based training programs; enhancing the availability of decontamination showers, standby intensive care unit capacity, negative pressure rooms, and appropriate personal protective equipment; and conducting international collaborative research on the civilian consequences of conventional weapons of terrorism. The trend is toward decreased, not increased, funding. The federal budget picture between now and 2019 is truly terrible. (Handrigan)
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 7.3 (EMS) See 8.2 (ED) below Research gaps and opportunities 8.1 (ED) Academic medical centers should support emergency and trauma care research by providing research time and adequate facilities for promising emergency care and trauma investigators, and by strongly considering the establishment of autonomous departments of emergency medicine. Recommendation not directed to the federal partners. 8.2 (ED) The Secretary of HHS should conduct a study to examine the gaps and opportunities in emergency care research, including pediatric emergency care, and recommend a strategy for the optimal organization and funding of the research effort. This study should include consideration of the training of new investigators, involvement of emergency and trauma care researchers in grant review and advisory processes, and improved research coordination through a dedicated center or institute. Congress and federal agencies involved in emergency and trauma care research (including DOT, HHS, DHS, and DOD) should implement the study’s recommendations. The NIH has moved forward substantially on this, for example by convening a Roundtable on Emergency Care that examined issues in the conduct of emergency care research. The other federal partners need to move forward on this as well, and coordinate their efforts. (Handrigan) The EMS-C program provided FICEMS with gap analysis of prehospital research. This analysis is inclusive of all ages, not just pediatric. The report noted that the literature in the prehospital setting continues to be largely non-randomized control trials conducted as retrospective observational studies. The majority of the recommendations of the research agendas continue to be unmet. Particularly lacking is research in optimal methods of education and competency assessment, quality and patient safety, and trauma management. (Kavanaugh) 8.3 (ED) States should ease their restrictions on informed consent to match federal law. Recommendation not directed to the federal partners.
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Rec # (Report) IOM Recommendation Federal Response 8.4 (ED) Congress should modify Federalwide Assurance (FWA) Program regulations to allow the acquisition of limited, linked, patient outcome data without the existence of Federalwide Assurance Program. While no recent legislation addressing Federalwide Assurance could be located, it is no recommendation that deserves attention (Handrigan). SOURCES: Dawson (2009); Handrigan (2009); Kavanaugh (2009); IOM (2006a,b,c). REFERENCES Dawson, D. 2009. Emergency Medical Services at a Crossroads Implementation Update. PowerPoint slides presented at the National Emergency Care Enterprise Workshop, Washington, DC. Handrigan, M. 2009. Hospital-Based Emergency Care: At the Breaking Point. May 2009. PowerPoint slides presented at the National Emergency Care Enterprise Workshop, Washington, DC. Kavanaugh, D. 2009. PowerPoint slides presented at the National Emergency Care Enterprise Workshop, Washington, DC. Institute of Medicine, 2006a. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. Institute of Medicine, 2006b. Emergency Medical Services at a Crossroads. Washington, DC: The National Academies Press. Institute of Medicine, 2006c. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press.
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