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Federal Progress Reports: Advancing Emergency and Trauma Care

WORKSHOP OVERVIEW

Arthur Kellermann, the workshop chair and an original member of the Institute of Medicine (IOM) Committee on the Future of Emergency Care in the United States Health Care System, started the day’s discussions with a brief description of the five most central recommendations from the IOM reports. The first of these, he said, was that the health care system should end the practices of boarding and emergency medical services (EMS) diversion. Second, emergency care should be regionalized. (This was to be the subject of a subsequent IOM workshop in September 2009.) Third, a lead federal agency should be designated with responsibility for advancing emergency care. He said a single entity is needed to coordinate and create synergies, eliminate confusion, and promote a more efficient allocation of federal resources. Fourth, pediatric emergency care should be strengthened (as was detailed in one of the three committee reports). Fifth, the organization and funding of emergency care research should be improved.

In the past 3 years, Kellermann observed, the three reports had a tremendous impact on the public and on policy makers. He cited several developments to back up this claim. The goal of this workshop, he said, is to provide an opportunity to revisit the committee’s recommendations, assess the progress that has been made in achieving the committee’s overall vision, and consider where the federal partners might focus their efforts going forward.



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1 Federal Progress Reports: Advancing Emergency and Trauma Care WORKSHOP OVERVIEW Arthur Kellermann, the workshop chair and an original member of the Institute of Medicine (IOM) Committee on the Future of Emergency Care in the United States Health Care System, started the day’s discussions with a brief description of the five most central recommendations from the IOM reports. The first of these, he said, was that the health care system should end the practices of boarding and emergency medical services (EMS) diversion. Second, emergency care should be regionalized. (This was to be the subject of a subsequent IOM workshop in September 2009.) Third, a lead federal agency should be designated with responsibility for advancing emergency care. He said a single entity is needed to coordinate and create synergies, eliminate confusion, and promote a more efficient allocation of federal resources. Fourth, pediatric emergency care should be strengthened (as was detailed in one of the three committee reports). Fifth, the organiza- tion and funding of emergency care research should be improved. In the past 3 years, Kellermann observed, the three reports had a tremendous impact on the public and on policy makers. He cited several developments to back up this claim. The goal of this workshop, he said, is to provide an opportunity to revisit the committee’s recommendations, assess the progress that has been made in achieving the committee’s overall vision, and consider where the federal partners might focus their efforts going forward. 

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 NATIONAL EMERGENCY CARE ENTERPRISE KEYNOTE ADDRESS The workshop’s keynote speaker was Dr. Jeff Runge, former assistant secretary for health affairs at the Department of Homeland Security (DHS), former administrator of the National Highway Traffic Safety Administra- tion (NHTSA), and now president of Biologue, Inc. Dr. Runge commented that he had high hopes for the three IOM reports on emergency care when they were released in 2006, but he acknowledged that the fundamental changes called for in the reports take time to achieve. He criticized the original committee for proposing so many recommendations, and noted that fully implementing them will require substantial cultural change. To get a sense of who was in the audience, Runge asked the participants to raise their hands and identify themselves as practitioners of emergency care or policy makers. More than half responded that they were prac- titioners. He also asked the audience members to indicate if they had ever been a patient in an emergency department, or had a family member who was a patient. The vast majority of hands went up. Runge then asked the audience to assess how we, as a community, are doing in advancing the cultural change envisioned by the IOM reports. He identified a series of topic areas that grouped together the IOM recommen- dations and asked the audience to assign a letter grade (A, B, C, or F) to each area based on a show of hands. The topic areas included the following: • Operational efficiency (e.g., reducing boarding and ambulance diversion) • Information technology • The burden of uncompensated care • Emergency care workforce (e.g., availability of on-call specialists) • Research in emergency care • Emergency care for children (e.g., defining pediatric competencies) • Pediatric safety • Emergency care funding • Payment for medical care without transport • Air medical services • National standards for training and credentialing (e.g., accept national certification as a prerequisite of state licensure; common scopes of practice across states) • Disaster preparedness In virtually every case the majority of hands indicated a low letter grade, typically a C or an F. In discussing an overall grade, Runge pointed out that a number of key indicators have not shown any improvement in the past 3 years. For example, he said that EMS diversion has not ended or even improved. There

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 FEDERAL PROGRESS REPORTS are still over half a million ambulance diversions per year. The “boarding” of admitted patients in emergency department (ED) treatment spaces has not been appreciably reduced. Fewer specialists than ever are willing to take an emergency call. Furthermore, the numerous problems associated with the Emergency Medical Treatment and Active Labor Act (EMTALA)—­the federal law mandating that hospital emergency departments care for all in need without regard for their ability to pay—­have not changed. Runge remarked that in many cases, IOM reports instigate change by catalyzing a reaction that has already begun to take place. The problem in the case of the emergency care reports, he said, was that there was very little chemical reaction going on at the time of their release, and it is very difficult to catalyze something without reagents. What is needed, Runge said, is a more well-defined plan for change—­ one that includes not just assignments, but also timelines, dedicated funding, and perhaps most importantly, leadership. Someone must be in charge of making change happen. The IOM reports provide the outlines of a plan, Runge argued, but they do not fulfill these requirements. Runge shared a story about the White House Homeland Security Council’s efforts to create a national strategy for pandemic influenza during the Bush Administration. He said that the Council, along with representa- tives of the relevant departments and agencies, developed a large implemen- tation plan with hundreds of tasks assigned to the federal agencies, states, and many others. This produced a plan that was thicker than a New York City phone book. At that point, a planning expert from the military was brought in to review the effort. She pointed out that North Atlantic Treaty Organization’s (NATO’s) strategic plan to defend Europe was only about 25–30 pages long. Therefore, Runge asserted, you don’t need a lengthy plan to prepare for a challenge—­just a simple, workable, prioritized plan that is based on sound methodology. Runge challenged the audience to identify the person whose “day job” it is to promote the needed cultural change in emergency care. Good plans are based on a commander’s intent, and for that a commander is needed. The plan then needs to identify the players and the capabilities required to execute the mission. It must identify the required actions and assign roles and responsibilities for executing those actions, along with time lines. Finally, each role and responsibility needs to have a budget attached to it. Ongoing, everyday funding is required, Runge said. “You can’t grant your way out of this problem.” Runge said he examined all the recommendations contained in the IOM reports and listed who had been tasked with responsibility. He found that the hospital-based emergency care report contained 19 different objectives with 35 tasks. The EMS report contained 17 unique objectives and 33 tasks. The pediatric report contained 12 different objectives and 31 tasks. Overall,

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 NATIONAL EMERGENCY CARE ENTERPRISE the three reports contained 99 different tasks assigned to many different actors, including the Department of Health and Human Services (HHS), Department of Transportation (DOT), DHS, Department of Defense, Con- gress, the states, hospitals, EMS agencies, the Joint Commission, profes- sional associations, educational institutions, industry, and many others. These tasks and objectives can be divided into various categories, such as reimbursement, curriculum design, standards, performance indicators, state legislation, changes in medical and EMS practice, hospital operations, and competitive cooperation among disparate and usually fighting groups. He commented that each one of these topics is massive and could be con- sidered someone’s life work, even if they worked full time to accomplish it. Thus these tasks need to be prioritized. He recommended a triage process to identify those recommendations that will yield the greatest bang for the buck. He conceded, however, that this will require consensus among stake- holders, which can be difficult to achieve. The most acute needs in emergency care, he said, include leadership at the highest levels of the executive branch. The President needs to know and acknowledge that the emergency care system warrants attention. In addi- tion, he said, the issue needs champions in both houses of Congress and on both sides of the aisle. In addition, economists must be engaged, because no change will occur without cost/benefit analyses. Ultimately, Runge said, cultural change will come about when all the people who have been a patient in an emergency department, or who have accompanied friends and family members there, demand that the system be strengthened. Runge closed by noting another obstacle to progress: the current culture among emergency care personnel to “suck it up” and get the job done, no matter what. When the ED’s hallways fill up and patient loads increase to unmanageable levels, when prehospital personnel are forced to respond to one call after the other, emergency care personnel tend to work harder and somehow get the job done. But by doing so, he noted, they enable the rest of the health care system to ignore the problem. Now, he said, “It’s time to cry uncle.” FEDERAL PROGRESS REPORTS Following the keynote address, three federal officials—­Michael Handrigan (HHS/Office of the Assistant Secretary for Preparedness and Response [ASPR]), Drew Dawson (DOT/NHTSA), and Dan Kavanaugh (HHS/Health Resources and Services Administration [HRSA])—­provided updates on efforts to improve emergency care within their departments and agencies. These presentations corresponded with the three IOM reports. Handrigan provided an update on progress toward achieving the recommen-

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 FEDERAL PROGRESS REPORTS dations of the hospital-based emergency care report, Dawson detailed activi- ties pertaining to the recommendations in the EMS report, and Kavanaugh described progress toward achieving the pediatric report’s recommendations. The federal activities reported by the speakers are detailed in Appendix C. Handrigan, acting director of the new Emergency Care Coordina - tion Center (ECCC) within ASPR, led off the discussion. He said that the process of reevaluating the recommendations from the 2006 IOM reports would help the federal partners in focusing their agenda and policies. He expressed hope that the workshop would facilitate the crafting of a realistic and achievable plan. Handrigan cited several positive developments that addressed recom- mendations set forth by the IOM in 2006. He noted, for example, that the creation of the ECCC, which received its charter in January 2009, is a direct federal answer to the IOM’s call for a federal lead agency (Recom- mendation 3.6). The establishment of the Council on Emergency Medical Care (CEMC), which he chairs, brings together partners from all levels of government and a range of subject-matter and policy experts to coordinate the federal agenda on emergency care. One function of this group is also to examine performance indicators, a goal set forth by the IOM in Recom- mendation 3.3. In other areas, Handrigan said, little has been achieved to date. For example, Recommendation 2.1 stated that Congress should establish dedi- cated funding, separate from Medicaid Disproportionate Share payments, to reimburse hospitals that provide significant amounts of uncompensated emergency and trauma care. Although there has been some legislation that pertains to a very small number of states, Handrigan said, “I would propose that this recommendation has gone unanswered today.” (See Appendix C for additional updates.) Dawson, director of the Office of Emergency Medical Services at NHTSA, noted that the National Emergency Care Enterprise consists of a hospital-based component (the primary focus of the ECCC) and a prehospital component, which is the primary focus of NHTSA and the Federal Interagency Committee on Emergency Medical Services (FICEMS). FICEMS is mandated by the DOT reauthorization statute. It provides a focal point for the coordination of EMS activities in the federal govern- ment. FICEMS was created by Congress and is jointly convened by the Secretaries of DOT, HHS, and DHS. NHTSA provides primary adminis- trative support. Some of FICEMS’ priorities include submission of an annual report to Congress, EMS data standardization and collection, EMS disaster pre- paredness assessment and needs, EMS research funding review, and sup- porting improvements in medical oversight. NHTSA has produced two annual reports to FICEMS on the progress federal agencies have made in

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0 NATIONAL EMERGENCY CARE ENTERPRISE implementing the 2006 IOM report, as well as identifying opportunities for future collaboration. Dawson highlighted two activities that substantially relate to the emer- gency care enterprise and address IOM report recommendations. First, he said, the National EMS Advisory Council (NEMSAC) now provides an opportunity for nonfederal players to come together across a broad spectrum of emergency medical services and provide input to the DOT and FICEMS. Second, the National Emergency Medical Services Information System (NEMSIS) is central to addressing many of the recommendations contained in the IOM report. NEMSIS includes a national uniform XML standard dataset and a national EMS database that currently contains approximately 6 million patient records from across the United States. Cur- rently, 16 states submit records to this database. Development of NEMSIS dataset version 3.0 is under way. It will ensure its integration with electronic health records meeting HL7 standards. Finally, Dawson reported that excellent progress has been made on the IOM recommendation concerning the development of evidence-based pro- tocols for the treatment, triage, and transport of out-of-hospital patients. He said that NHTSA, along with FICEMS and NEMSAC, have committed to establishing an evidence-based guideline development process to translate new discoveries into EMS practice. A consensus-building meeting was held in September 2008 to solicit input from the national EMS community and to provide national and international perspectives on the guideline develop- ment process. Rather than produce a static set of protocols, the conference has proposed a mechanism for ongoing review of evidence and its transla- tion into practice. A one-page Draft National Model for EMS Evidence-Based Guidelines Development outlines how this process might work. Data and research will enter the process, along with current guidelines. This evidence will be appraised and graded recommendations will be developed based on the strength of the evidence. Eventually, practice standards may be adjusted through a variety of mechanisms. The Emergency Medical Services for Children (EMS-C) program has already pilot-tested a portion of this model, focusing on prehospital management of pediatric seizures. Updates on other recommendations contained in the IOM EMS report are contained in Appendix C. Kavanaugh, senior program manager for the EMS-C program at the Maternal and Child Health Bureau of HRSA, described a number of recent activities related to improved pediatric research. He noted that last year, the National Institutes of Health released Program Announcement Review 08-261, which centers on research on emergency medical services for chil- dren. It invites the submission of applications focusing on research in the following areas: prevention research to reduce the need for emergency care;

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 FEDERAL PROGRESS REPORTS clinical research to ensure children receive high-quality and appropriate medical, nursing, and mental health care in an emergency; health systems research from prehospital care to the emergency department to in-patient care and the return to the community; models to improve service and cost efficiency in pediatric emergency care; and studies to improve the quality of the research conducted. Kavanaugh also noted that HRSA’s EMS-C program funds the Pediatric Emergency Care Applied Research Network (PECARN). He said that since the release of the IOM report, EMS-C’s support for PECARN has increased by about 30 percent. HRSA primarily funds PECARN’s infrastructure. It also provides some funding for pilot studies. The Network must secure the direct costs it needs to conduct major projects from research agencies. The EMS-C program also supports the National EMS-C Data Analysis Resource Center. This center helps EMS-C grantees and state EMS offices develop their capabilities to collect, analyze, and use EMS data to improve the delivery of emergency and trauma care. To examine a detailed summary of federal progress toward achieving the 2006 IOM report recommendations, see Appendix C. AUDIENCE DISCUSSION Following the federal partner presentations, audience members had an opportunity to pose questions and to make additional comments. Ricardo Martinez, an emergency physician and former NHTSA Administrator, said he learned a valuable lesson while working in the federal government: the need to have a champion backing your cause. Then he asked, “Where are the champions for emergency care in Congress?” He noted that the House turns over every 2 years. On the Senate side, he said, one Senator can make something happen or completely stop it. He said one strategy should be to identify people to rally around in Congress. Art Kellermann was asked to identify some of the champions now in Congress. He complimented the work of several members, including Sena- tor Daniel Inouye (D-HI), who has been a champion for EMS-C for many years; Rep. Henry Waxman (D-CA), who held hearings during his brief tenure on the Oversight Committee; Senators Richard Burr (R-NC) and Edward Kennedy (D-MA) for shepherding the Pandemic and All Hazards Preparedness Act through Congress; and others such as Reps. Pete Sessions (R-TX) and Bart Gordon (D-TN), who have worked to advance legislation through the House of Representatives. Although there are champions for emergency care in Congress, the issues we are discussing today clearly need more attention and focus, he said. Sandy Schneider from the University of Rochester and a member of the board of the American College of Emergency Physicians (ACEP) said that

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 NATIONAL EMERGENCY CARE ENTERPRISE one of the central recommendations from the IOM reports was to end the practice of boarding in hospitals. Yet, she said, she did not detect a lot of movement in this area from the federal agencies. She said that at this point, hospitals do not seem interested in doing anything about the problem. She challenged the panel to identify the best strategy, in terms of a federal response, to end boarding. Handrigan noted that the Government Accountability Office (GAO) had issued a previous report on ED crowding in 2003 and is about to release a new one. Handrigan said the new report will conclude that crowding was bad then and is worse now. He thought this would be a prime opportunity to push the agenda to the forefront and ask for answers from federal partners. (Editorial note: the report has since been released. It is entitled Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer Than Recommended Time Frames, GAO-0-4, 2009). Dawson said this issue has become a high priority for the Technical Working Group of FICEMS and for FICEMS as a whole. He said it had also been discussed at the Council on Emergency Medical Care (CEMC), and that it is probably an area where they can work together. Susan Nedza of the American Medical Association, and formerly the CMS medical director for the Midwest Region, said that research priorities seem to focus on inputs at the first level of care, but issues pertaining to interfacility transfers should probably receive more attention. Cases where one facility has stabilized a patient but cannot arrange needed transfer to another facility raise questions about whether some networks have adequate capacity for regionalization. Charlotte Yeh responded that Carolyn Clancy, director of the Agency for Healthcare Research and Quality, has assembled a task force to look at the issue of interfacility transfers and specifically the need for additional research in that area. Handrigan added that “research agendas are not hard to find; every- body has one.” He said the principal mission for the ECCC is to look at all the federal agencies that are engaging in research activities, figure out where the overlaps and gaps are, and help the agencies devise a more coordinated research direction, if not an agenda. He said that the ECCC, CEMC, and FICEMS are tackling this issue together. Alex Valadka, a neurosurgeon from Texas, agreed that interfacility transfers are a huge issue. From his point of view, many patients are transferred unnecessarily. He argued that better telecommunications, tele- radiology, and communication with outlying facilities could avoid situations in which tertiary care hospitals fill up with people who don’t need to be there, blocking access to care for more severe cases. Tom Scalea, physician-in-chief from the Shock Trauma Center in Baltimore, Maryland, said that some of the areas where we have made the

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 FEDERAL PROGRESS REPORTS least progress since 2006 relate to tasks assigned to professional societies. Presumably, he said, that is because these recommendations do not advance the specialties’ particular agendas. He asked what political muscle exists or should exist to cajole the professional societies into playing ball and helping these recommendations move forward. Dawson replied that the NHTSA has always gone about its business by actively involving professional associations in the decision-making process, so they feel they are part and parcel of the process. He said, “We [NHTSA] treat topics not as regulatory issues, but as issues we are working on together.” Kavanaugh said the EMS-C program has partnerships with stake- holders’ groups reflecting the broad spectrum of emergency care. Many professional organizations have representatives who are invaluable in terms of providing input to the program to ensure that it is responsive to the needs of the field. These organizations have always had a role in setting the direc- tion of the EMS-C program, he said. Developing public–private partnerships is important, Handrigan said. The federal government cannot tell professional societies what to do, and the professional societies cannot tell the federal government where to spend money. But there are instances where both sides can work together. One example, he said, occurred 2 weeks ago when the threat of a flu pandemic first emerged. The ECCC reached out to ACEP and together they quickly developed a project to provide guidance to the clinical community about how to manage a sustained surge of flu patients. He noted that public– private partnerships can help bring professional societies to the table in a productive way to work with federal partners. REFERENCE GAO (Government Accountability Office). 2009. Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer Than Recommended Time Frames. GAO-0-4. Washington, DC: Government Printing Office.

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