National Emergency Care Enterprise: Advancing Care Through Collaboration: Workshop Summary (2009)

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2 How Federal Policy Affects Emergency Care at the Community Level The workshop’s second full session began with a presentation from Linda McCaig of the National Center for Health Statistics (NCHS). She briefly presented emergency department (ED)-level estimates from the 2007 National Hospital Ambulatory Medical Care Survey. This survey provides nationally representative estimates on ED visits and EDs on an annual basis. In 2007, the NCHS added questions to the hospital survey based on the 2006 Institute of Medicine (IOM) report, in order to assess changes in ED crowding, she said. One survey question asks whether hospitals have an inpatient bed czar. Fifty-one percent of all EDs said they do (71 percent of all large EDs and 34 percent of small EDs). The survey also asked whether the ED had an observation or clinical decision unit. Overall, 36 percent did, includ- ing 54 percent of the large EDs and only about one third of the small and medium-sized EDs. The survey also examined a list of items that had been named in the IOM report about optimizing ED efficiency, McCaig said. The survey found that 66 percent of all EDs have bedside registration, 40 percent have computer-assisted triage, and 35 percent have zone nursing. With respect to boarding, 63 percent of all EDs acknowledged that admitted ED patients often wait more than 2 hours for an in-patient bed. The figure was 87 percent among large EDs and 39 percent for small EDs. This is notable because big EDs provide a large majority of total ED visits in the United States. Finally, the survey attempted to track rates of ambulance diversion. It asked, “What is the total number of hours that your ED was on diversion during the past year?” The first year this question was added, nearly all 15 

16 NATIONAL EMERGENCY CARE ENTERPRISE hospitals answered it. This is how the NCHS produced its estimate that U.S. hospitals diverted more than 500,000 ambulances in 2003. Since then, McCaig said, high nonresponse rates for this particular survey item have precluded the NCHS from updating its estimate. As a result, the NCHS cannot determine whether diversions are increasing or decreasing in frequency. GENERAL AUDIENCE DISCUSSION Following the opening presentation, Mary Jagim, client engagement man- ager for Intelligent InSites and 2006 IOM committee member, facilitated a general discussion of how federal policy affects emergency care at the com- munity level. This was the first opportunity for the audience to engage each other. Jagim asked audience members to consider the role that the federal trauma program, administered for many years by the Health Resources and Services Administration (HRSA), played in establishing and maintaining state and local trauma programs. Robert Bass, executive director of Maryland’s state emergency medi- cal services (EMS) agency, said the HRSA program had an impact in a couple different ways. First, it helped states that had not been able to get trauma systems up and running. It provided a small amount of funding, but this was sufficient for states to hire someone to run the program, begin to collect data, and provide a forum for trauma-related activities. Second, in those states that had functioning trauma systems, the federal program helped them to mature. These states were able to develop statewide bypass protocols, conduct additional data analysis, and perform other functions. However, Bass noted that since the HRSA program was eliminated 3 years ago, progress has stopped. Nels Sanddal, of the Critical Illness and Trauma Foundation and a tech- nical consultant to the American College of Surgeons (ACS) Trauma System Planning and Evaluation Committee, said that even though only about $40,000 a year was going out to certain states to assist with trauma system planning and development, many states had been able to hire a part-time, or in some cases, a full-time staff member with that money. Trauma surgeon Jerry Jurkovich, with the American Association for Surgery and Trauma, added that this was the person whose job it was to see the trauma system- building effort through to the end. Sanddal said the absence of those HRSA funds, and more importantly the loss of structured leadership at the state level, has hurt trauma efforts substantially. Finally, Sanddal noted that the termination of HRSA’s program meant the loss of two technical assistance centers devoted to trauma system planning and development nationwide. John Fildes, chief of the Division of Trauma & Critical Care at the University of Nevada School of Medicine and chair of the Committee on 

HOW FEDERAL POLICY AFFECTS EMERGENCY CARE 17 Trauma (COT), said that when the HRSA program was shut down, it cre- ated a complete vacuum of coordinated national leadership. In an effort to fill the gap, the ACS increased efforts and became what he described as “a surrogate for any sort of national coordination of injury care.” He said that ACS-COT fielded questions from state agencies, counties, cities, individual hospitals, and even individual practitioners, nurses, and prehospital person- nel. The ACS instituted verification programming, professional standard setting, quality projects, and the development of quality-based metrics using trauma registry, similar to what the United Network for Organ Sharing does for transplants. However, Fildes acknowledged there are limits to what a professional organization can do. First, he pointed out that their work on this has been “funded on the backs of dues-paying members.” Plus, stakeholder groups have limited authority. “We just don’t have the clout, and we can’t get everyone to sing from the same playbook,” Fildes said. If the ACS were to develop a template or blueprint for a trauma system model, “Who is going to say that from state-to-state or county-to-county or city-to-city, that this is the template or blueprint that must be applied?” Moreover, who would fund the incentive payments necessary to encourage other systems to apply it? Sanddal noted that the model trauma planning and evaluation docu- ment was produced as one of the last acts of the federal HRSA program. But without a champion to promote it, the kind of engaged dialogue that is needed with public health colleagues hasn’t taken place. Susan Nedza of the American Medical Association said that one of the more unfortunate things that has happened, even beyond the loss of funding, is that there has been a loss of leadership needed to integrate EMS and public health at the federal level. Bass, from Maryland, noted the responsibilities taken on by the National Association of State EMS Officials (NASEMSO) following the elimination of the federal HRSA program. “It came to us, this vacuum out there,” Bass said. In response, NASEMSO now hosts the Council of State Trauma Coordinators. THE ROLE OF GOVERNMENTS AND LOCAL PROVIDERS Dia Gainor, state EMS director from Idaho, said that the U.S. Constitu- tion specifies that unless the federal government is specifically tasked with a responsibility, then that responsibility is left to the states. This has resulted in tremendous disparities across the country. On the other hand, she noted that the federal government does not always place the right requirements on states. For example, we need to “stop the ridiculousness of focusing on planning for ‘The Big One’,” Gainor said. In her role as state regula- tor of EMS systems, she has to plan for events that may require care of up 

18 NATIONAL EMERGENCY CARE ENTERPRISE to 500 patients, when in reality, the current system there cannot handle 50 patients, she said. Keynote speaker Jeff Runge said one reason we are always preparing for The Big One is because of where the federal lead agency for emergency care has been placed on the government’s organizational chart. He observed that the IOM recommendation for the federal government to establish a lead agency was originally assigned to Congress, but the Emergency Care Coordination Center (ECCC) actually came into existence through an executive branch order: Homeland Security Presidential Directive-21. This lead agency “has a toehold in the federal government, but there is no indentation in the rock for the fingers right now,” Runge said. The agency is currently located in the Office of the Assistant Secretary for Preparedness and Response, “separated well away from the Secretary or anybody else who has a legislative agenda.” He urged Congress to push this lead agency higher up the department’s organizational chart. Runge noted that the original vision of the IOM was that this lead agency would be responsible for coordinating all emergency care funding. “This was probably a bridge too far,” he said. The only person in govern- ment who has that level of responsibility right now is the director of national intelligence (DNI). In the current federal structure, he said, the Secretary of Homeland Security cannot say how the U.S. Department of Health and Human Services spends its disaster funds. Although the final shape of this federal emergency care structure is unclear, legislative efforts continue to move forward. Adrienne ­ Roberts, senior manager for legislative affairs at the American Association of N ­ eurological Surgeons, noted that a number of legislative activities are under way at the congressional level. These include overall health system reform efforts, as well as legislation from Sens. Patty Murray (D-WA) and Jack Reed (D-RI) that would provide authorization language for ECCC regarding emergency care regionalization. That program is included in President Obama’s FY 2010 budget. Aside from these federal activities, several participants emphasized the importance of state and local responsibilities. Sanddal said many of the problems confronting emergency care systems need to be fixed at a regional level with state leadership. Nedza added, “This really is about communities, especially when you talk about regionalization.” Ron Anderson, president and chief executive officer at Parkland Health & Hospital System in ­Dallas, said, “Frankly, when you talk about the national trauma anything, I am a little suspect, because most of this is local. It really depends upon the hos- pital and the hospital’s willingness to be a communitarian and meet that community’s needs.” Anderson does not believe his hospital has been influenced much by developments at the federal level, although he does acknowledge experi- 

HOW FEDERAL POLICY AFFECTS EMERGENCY CARE 19 encing a “lack of coordination and a lack of regionalization, particularly in times of disaster.” He pointed out that “We pulled together for Katrina and Hurricane Ike. We took care of 30,000 evacuees. . . . In challenging times, everybody pulls together and does it, but there really isn’t the kind of c ­ oordinated planning that we need across state borders, across governmental borders, with Mexico, and that sort of thing.” Many problems experienced at the level of day-to-day emergency care are local responsibilities, he said. For example, Anderson highlighted staffing issues. He said that many ­Dallas hospitals, such as boutique, physician-owned hospitals, have abrogated their public responsibility by recruiting physicians with a promise that they will never have to provide on-call services. This means fewer physicians are now available in the local area to take trauma and emergency calls. In addi- tion, some of these hospital emergency departments have made themselves less accessible by moving to the suburbs. He said, “You can’t find their ER anymore. It’s like a speakeasy.” Alex Valadka, a neurosurgeon from Texas, said that many of these issues, such as boarding, EMS diversion, difficulty with interhospital trans- fers, and limited access to specialists, are really the hospitals’ problems. The concepts of regionalizing care, coordination of call, and sharing resources will be driven by hospitals, he said. Ricardo Martinez, former administrator of the National Highway Traffic Safety Administration and now executive vice president of The Schumacher Group, has worked with more than 100 hospitals in rural areas and bigger cities. He said he knows of surgeons who go off call when there is a patient in the ER who has abdominal pain, but no insurance. They immediately go back on call once the patient is transferred elsewhere. He knows surgeons who are giving up their privileges to be able to handle chest tubes. That way, after an ED physician puts a chest tube in, the patient must be transferred to a different facility (see also Chapter 5 regarding specialization). Martinez said these limitations in on-call availability result in overtransfers, a practice Anderson bluntly described as “patient dumping.” Martinez has begun an effort to develop more constructive relationships among some of the tertiary referral centers and the rural facilities in their network. They have held dinners to get people to talk to each other. In these meetings, he observed, “There is a lot of anger and a lot of miscommunica- tion and (even) a lot of lying, which leads to discussion. When you have the discussion, you start finding out that what we are trying to create is dia- logue.” Martinez’s organization is now looking at establishing a connected network in which telemedicine technology will enable more patients to be cared for locally with information transmitted from tertiary hospitals. Anderson was among the people involved in writing the original Emer- gency Medical Treatment and Active Labor Act (EMTALA) regulations. The Act was intended to protect patients against dumping, but, he said, “It’s 

20 NATIONAL EMERGENCY CARE ENTERPRISE a double-edged sword now.” Once people learned how to create institu- tions that are exempt from EMTALA provisions, they can dump legally. In response to Jagim’s question about the role of the federal government in this situation, Anderson replied that one of the worst things his hospital has to deal with is a local problem—hospitals not taking calls in their specialty. He said we need to deal with the issue of whether hospitals should be allowed to opt out and not truly be a 24/7 operation. Allowing the marketplace to decide will result in decisions we won’t like. Instead, he said, “This [emer- gency care] ought to be treated like a utility.” Jurkovich argued that crowded emergency departments should be viewed as local problems. “If your ER is crowded because you have too many private cardiac surgery patients who are taking up the beds, that is not a national problem, that is a local problem,” he said. He described a local solution to the problem of intoxicated patients, who were regularly dumped on safety net facilities. Rather than allowing matters to reach the point where the safety net hospital might refuse to accept these patients, the local private hospitals pooled their resources to fund a “detox unit,” staffed by a nurse practitioner or a physician assistant. Intoxicated patients spend up to 8 hours there, and if they remain sick, they are taken to the emergency room. Jurkovich said the funding for the unit was contributed by all hospitals in the city, not just the safety net hospital. They all agreed to it because they did not want to take these patients themselves, he said. Anderson said, “I think we ought to do everything we can to provide an alternative to the emergency room, because that is where we get bogged down. When I have got all these people waiting in the emergency room, crowding the place up, the really sick patients get misplaced, and occasion- ally we make a mis-triage.” However, Angela Gardener of the American College of Emergency Physicians said, “One of our biggest problems is the prevailing belief in this town [Washington] that if we just got people out of the ER, our prob- lems would be solved. I am here to tell you, that isn’t the case.” She said some influential members of Congress believe that half of the care in the emergency departments belongs in primary care settings. But Gardener said that, according to the Centers for Disease Control and Prevention, the figure is only 12 percent. However, Anderson said he recalled research he had done back in the mid-1990s that found that, at that time, 43 percent of ED visits nationwide could be managed or prevented with better access to primary care. INTERNATIONAL APPROACHES TO ED CROWDING Runge noted that while the industrial managers and architects say that “form follows function,” the reality is that “form follows finance.” Jesse 

HOW FEDERAL POLICY AFFECTS EMERGENCY CARE 21 Pines from the University of Pennsylvania agreed, adding that the problems of boarding and on-call coverage are due to the current payment system, which favors elective patients over emergency patients (see Chapter 6). This contributes to a situation in which we spend nearly $8,000 per person per year on health care, yet experience shortages of resources, Pines said. Many other countries, including Australia, England, and New Zealand, have decided that ED patients will spend a limited amount of time in the emergency department, he observed. Hospital administrators in England have actually lost their jobs over failing to meet this standard. He called on the U.S. government to implement stringent requirements for how long patients will be allowed to spend in the ED. Dr. Jon Mark Hirshon of the University of Maryland noted that England and Canada simply do not accept boarding. Hospitals in England operate under a funding mechanism that specifies that the patient must be out of the ED within 4 hours. He said that the Centers for Medicare & Medicaid Services could drive improvements by requiring hospitals to keep track of how long people wait in the ED and by decreasing reimbursements in cases when the wait times are too long. Jagim said the community ministry of health in British Columbia, Canada, has implemented a pay-for-performance system for EDs. They use the Canadian triage acuity scale, which assigns a target length of stay to patients based on their acuity. For example, if a 2-hour stay is targeted, hospitals will receive $100 if the care is completed within this amount of time. One hospital in British Columbia that has been particularly effective in this pay-for-performance system took half the revenue from these pay- ments and invested it in programs to enhance their throughput capabilities. They used the other half to provide care in the community and help prevent patients from needing to come to the ED in the first place. Handrigan observed that pay-for-performance in the United States typically provides only a marginal increase in payment. He questioned how substantial payments would need to be to produce significant investments, either in in-house resources or community programs. Sandra Schneider, emergency physician from the University of ­Rochester, said different countries have used different incentives. England has put a fair amount of money into the effort. Ireland, however, simply relied on public reporting of hospital performance. Within about a year, Schneider remarked, all hospitals there had come up to the new standard. Australia has also put some money put into its system, she said, but public reporting in the newspaper drove the improvements. If the United States tried to implement a time limit as these other countries have done, some emergency physicians believe they will never be able to meet it because of the time needed to work up patients and discharge them from the ED. However, Schneider believes that if such a rule were implemented in the United States, it would align 

22 NATIONAL EMERGENCY CARE ENTERPRISE emergency physicians with the hospitals, allowing them to fix systems that are now broken and meet the same time constraints other countries have. Anderson of Parkland in Dallas noted that hospitals with residency programs will soon be required to start releasing people in 4 hours, or 8 hours if they are admitted upstairs. He said these criteria will be imposed by residency review committees. Most hospitals do not meet those criteria today, but these training groups will act as regulators and instruct hospitals on what they have to do, regardless of the public payors. Trauma System Support Many states have struggled with obtaining financial support for their trauma systems. Tom Scalea, from the University of Maryland Medical Center, noted that Maryland has had an organized trauma system for almost 40 years and one secret to its success has been the ability to establish link- ages between the emergency and trauma care systems. The state has a trauma network of nine centers and they have close relationships with all of the EMS agencies, the Maryland Fire and Rescue Institute, and all of the prehospital provider networks. Together, these constitute an enormously powerful lobby. Every time they have gone to the state for additional fund- ing because the system is at risk, the people of Maryland have responded, he said. For example, this year after a emergency rescue helicopter crashed, these groups launched an effective lobbying campaign and the state decided to allocate an additional $50 million for new helicopters. Idaho offers a stark contrast, Gainor said. She said that Idaho is in the abysmal situation of having legislative language that specifically prohibits the state from developing a trauma system. Without intervention from the federal government, Gainor said, this situation will continue. Georgia has also faced difficulties raising revenue for its trauma sys- tem. Workshop chair Arthur Kellermann said this was partly because of the paradox of professionalism, or what Runge described in Chapter 1 as the “suck it up” phenomenon. Kellermann recalled a meeting several years ago in which a member of Congress advised a roomful of emergency physi- cians that “You are your own worst enemies, because you keep pulling it off. You do whatever you need to do to take care of the patient in front of you.” This year, for the second year in a row, despite overwhelming public support, overwhelming votes in both chambers, and the putative support of the state’s leadership, Georgia’s General Assembly failed to pass a bill to fund a trauma care network in the state, Kellermann said. “Basically, they dared the hospitals and the existing system to fall apart, which it will not do, because we will suck it up the best we can.” The Congressman Kellermann quoted had praised the political will of a handful of orthopedic surgeons in Las Vegas. When they refused to take 

HOW FEDERAL POLICY AFFECTS EMERGENCY CARE 23 call, the hospital shut down its trauma center, precipitating a statewide crisis that forced the legislature to deal with the problem. Nevada trauma surgeon John Fildes responded that when this incident happened, the state’s trauma system was falling apart. The medical com- munity was holding it together with duct tape and baling wire. But Nevada surgeons and physicians are not shy, he said, and they decided they would not be enablers. “As a discipline, we have been codependent and enabling, and we have allowed people to push us around, thereby permitting bad care to be given to our patients,” Fildes said. Roger Lewis of Harbor–UCLA Medical Center noted the close asso- ciation between trauma care and general emergency care in the public’s perception. He said that a voter-backed initiative in California to increase the local sales tax to support the trauma system had passed, bolstering that part of the system. However, the people who are really suffering don’t have serious traumatic injuries, Lewis observed. They have medical diseases, minor injuries, social problems, and other undefined illnesses. Those are the people who have to wait and suffer, he said. The association between general emergency care and the trauma system has been both a blessing and a curse. It is a blessing in the sense that many hospitals stay afloat because they are recognized as major providers of trauma care. On the other hand, he said, after California’s sales tax increase was approved, his emergency department was still crowded. A number of his patients were heard to say, “I thought we fixed this.” Their assumption was that if the trauma center was supported, the hospital emergency department would also flow well. That has clearly not been the case. Finally, Jagim asked where the federal government could direct its money to make the biggest impact in terms of trauma and EMS systems. Trauma surgeon Jurkovich said there is a need to examine emergency and trauma care systems to determine what works, what does not work, and which models are most effective, then use the money to propagate effective models. He said that that would be a very helpful use for a modest amount of federal dollars. Valadka of Texas said he and neurosurgery colleagues in Seattle had conducted an unofficial survey of people in other major cities to determine what had worked in their local areas to improve emergency care. What they found was that every place was truly unique and the solutions were all over the map. So he recommends focusing on developing solutions that work locally. Nevertheless, he said, that is exactly why we need roundtables where everyone talks to each other. That way, people can identify ways to work together and go forward.